University of Massachusetts Chan Medical School - Baystate Health Springfield, MA
Andrew Ng, MD1, Sabah Sikander, DO2, Tiago Martins, DO1, Rony Ghaoui, MD3 1University of Massachusetts Chan Medical School - Baystate Health, Springfield, MA; 2Baystate Medical Center, Springfield, MA; 3University of Massachusetts Chan Medical School - Baystate Health, Westfield, MA Introduction: Severe autoimmune hepatitis (AIH) and acetaminophen (APAP) toxicity can present with elevated liver enzymes, elevated INR and jaundice. Both can lead to acute liver failure (ALF). We present a complex case of AIH confused for APAP toxicity in the setting of systemic lupus erythematosus (SLE).
Case Description/
Methods: A 38-year-old male with a history of SLE with lupus nephritis, antiphospholipid syndrome on warfarin, hypertension, hyperlipidemia presented with a complaint of 10 days of generalized joint pain and left flank pain.
He had a history of lupus flares with joint pain and presumed that his symptoms were related to a lupus flare. He used up to 5200 mg of APAP for his pain. He had not been on any medications for lupus as he was lost to follow up with rheumatology.
On presentation, he had an INR of 6.6, sodium 132 mmol/L, AST 475 units/L, ALT 367 units/L, ALP 447 units/L, bilirubin 1.4 mg/dL and APAP level of 8 mg/mL. Given his history, APAP toxicity was suspected, and n-acetyl cysteine (NAC) was started with minimal improvement. His total bilirubin continued to increase, which led to a concern for ALF. Thus, transfer to a liver transplant center was planned. He never developed hepatic encephalopathy. Given the continued elevation in his liver function tests, AIH was considered. He was found to have an anti-smooth muscle antibody titer ratio of 1:110 with elevated IgG levels 3072.
He then underwent a liver biopsy which showed prominent inflammatory activity, Kupffer cell aggregates, marked lobular and portal hepatitis, which confirmed AIH. He was then started on prednisone 60mg with clinical improvement. Once there was resolution in his cholestatic liver injury, he was started on azathioprine with a steroid taper. Discussion: There are dozens of documented cases of concurrent AIH and SLE. Thus, autoimmune hepatitis should be part of the differential of SLE patients with liver pathology. Here, APAP use in an SLE patient complicated the presentation and led to delayed recognition of AIH. Per the American Association for the Study of Liver Diseases, AIH is diagnosed with the presence of disease-congruent histological abnormalities (interface hepatitis), laboratory abnormalities (elevated liver enzymes and serum IgG concentration), and autoantibodies (antinuclear antibodies, smooth muscle antibodies, liver kidney microsome type 1 antibodies) and exclusion of resembling diseases. A broad differential without premature closure is important in evaluating and managing hepatic failure.
Disclosures: Andrew Ng indicated no relevant financial relationships. Sabah Sikander indicated no relevant financial relationships. Tiago Martins indicated no relevant financial relationships. Rony Ghaoui indicated no relevant financial relationships.
Andrew Ng, MD1, Sabah Sikander, DO2, Tiago Martins, DO1, Rony Ghaoui, MD3. P1747 - Acetaminophen Toxicity Delaying Recognition of Autoimmune Hepatitis in a Patient with Lupus, ACG 2025 Annual Scientific Meeting Abstracts. Phoenix, AZ: American College of Gastroenterology.
