S3512 When Your Defense Goes Rogue

Abstract

INTRODUCTION: Humans have innate and adaptive defense mechanisms that, collectively, protect us against diseases and infections. But a malfunction of our immune system may cause harm in the form of autoimmune diseases. CASE DESCRIPTION/METHODS: We present a 29 year old female with no PMH who sought outpatient evaluation for new onset jaundice. With the intent of losing weight, the patient followed a strict diet, consisting of apples and water with one ‘cheat’ meal per week. In conjunction, patient reported using a daily herbal extract with containing green tea and green coffee bean extract. There was no family history of liver or autoimmune disease. After 4 months, she developed nausea, vomiting and jaundice. She was hemodynamically stable and afebrile. With the exception of jaundice the physical examination was unremarkable. Imaging (CT and MRI) of the liver revealed periportal edema. Initial laboratory evaluation showed ALT 960, AST 1162, T BR 17.3 & INR 1.9. HBV, HCV, HSV, HIV, EBV and CMV, Wilson’s disease and alpha 1 antitrypsin deficiency were ruled out as the cause of the patient’s acute liver injury. ANA titer was 1:1280 with a speckled pattern. Antimitochondrial, smooth muscle and liver kidney microsomal antibodies were negative. Due to persistent decompensation, liver biopsy was done with extensive hepatic necrosis. She was ultimately diagnosed with autoimmune hepatitis and treated with corticosteroids and later azathioprine. DISCUSSION: Although acute liver injury induced by green tea consumption has been described, the association with autoimmune hepatitis has been rarely reported. Green tea leaves contain polyphenols, flavonols and catechinis. The polyphenols have antioxidant, anticarcinogenic, anti-inflammatory, thermogenic and antimicrobial properties. Green tea extract has been associated with acute hepatitis and fulminant hepatic failure. The mechanisms leading to cytotoxicity include mitochondrial membrane destruction and induction of reactive oxygen species. Patients with autoimmune hepatitis may have symptoms of jaundice with hypergammaglobulinemia and positive serum antibodies (ANA, smooth muscle and liver kidney microsomal). The liver develops inflammation, necrosis and fibrosis for which therapy with corticosteroids and azathioprine are used. These findings were noted in our patient after several months of green tea and green coffee bean consumption. Therefore we hypothesize that green tea may, in rare circumstances, be the trigger of autoimmune hepatitis.