article information

Archives of Pediatric Infectious Diseases: Vol.4, issue 3; e34653
published online: May 17, 2016
article type: Case Report
received: November 15, 2015
revised: February 14, 2016
accepted: February 14, 2016
DOI: https://doi.org/10.5812/pedinfect.34653
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Autoimmune Hepatitis as an Initial Presentation of SLE

authors:

avatar Mehrnoush Hassas Yeganeh 1 , avatar Neda Zafari 2 , avatar Mahsa Sardarinia 2 , avatar Leyla Mahboubi 1 , avatar Vadood Javadi Parvaneh 1 , avatar Shima Salehi 1 , avatar Reza Sinaii 1 , avatar Fatemeh Freshteh Mehregan 1 , avatar Khosro Rahmani 1 , avatar Reza Shiari ORCID 1 , *

Department of Paediatric Rheumatology, Mofid Children’s Hospital, Shahid Behshti University of Medical Sciences, Tehran, IR Iran
Medical Student, Mofid’s Children Hospital, Shahid Behshti University of Medical Sciences, Tehran, IR Iran

how to cite: Hassas Yeganeh M, Zafari N, Sardarinia M, Mahboubi L, Javadi Parvaneh V, et al. Autoimmune Hepatitis as an Initial Presentation of SLE. Arch Pediatr Infect Dis. 2016;4(3):e34653. https://doi.org/10.5812/pedinfect.34653.

Abstract

An 11-year-old female patient with autoimmune hepatitis (AIH) was referred to our rheumatology clinic due to her current musculoskeletal manifestations. The patient had been diagnosed with AIH 3 months previously, based on jaundice and impaired liver function tests, and she had been treated with low-dose prednisolone and azathioprine. She presented with malaise, arthritis, a malar rash on the face, and oral ulcers. Laboratory tests revealed a positive ANA/anti-dsDNA test. Liver biopsy showed chronic hepatitis with severe inflammatory activity, in favor of a diagnosis of definite AIH. She fulfilled the international criteria for both SLE and AIH. The clinical symptoms and laboratory findings of SLE improved with ongoing treatment with corticosteroids and azathioprine, accompanied with hydroxychloroquine sulfate. The present case indicates that AIH can be the first manifestation of SLE in children.

1. Introduction

Autoimmune hepatitis (AIH) is a chronic immune-mediated liver disorder, more prevalent in females, that is associated with high liver transaminase and immunoglobulin G levels, and histological changes due to inflammation in hepatocytes and liver tissue (1). It usually presents in children with nonspecific symptoms, such as malaise, lethargy, and arthralgia without arthritis. It can present either very acutely or more insidiously, but can progress rapidly and lead to cirrhosis in a relatively short period of time in untreated severe disease (2). AIH reflects a complex interaction between triggering factors, autoantigens, genetic predisposition, and immune regulatory mechanisms (3). Systemic lupus erythematosus (SLE) is a systemic autoimmune disease classically involving the skin, kidneys, and central nervous system. Several previous reports showed the manifestation of AIH in adult lupus patients (4-6); however, there are no reports of such an association between AIH and SLE in children. Both AIH and SLE have an autoimmune basis and hence can occur simultaneously or masquerading as presentations of each other. In this case report, we report AIH as the first manifestation of SLE in an 11-year-old girl.

2. Case Presentation

After obtaining IRB approval from our center’s ethics board, we decided to report this special case. An 11-year-old female patient was referred to the rheumatology department with complaints of anorexia, malaise, weight loss, pain in the sacroiliac joint accompanied by carpal joint swelling, and remarkable motion limitations. The patient had had icteric sclera for 3 months prior to her current presentation. Her parents did not agree for her to undergo liver biopsy at that time. Laboratory data revealed liver dysfunction, suggesting autoimmune hepatitis, and she underwent treatment for hepatitis (prednisolone 2 mg/kg daily with azathioprine 1 mg/kg). However, with the elimination of jaundice and decreased hepatic enzyme levels, the prednisolone dose was tapered. Low-dose prednisolone had been continued until she was referred to our clinic.

On her review of systems, she had photosensitivity (malar rash), oral ulcers, morning stiffness for about 1 hour, intermittent constipation and diarrhea, and hair loss. She also had a recent weight loss of about 2 kg. She is the third child of her family and was born via vaginal delivery. There was no consanguinity between the parents. Family history was negative for rheumatic or inherited liver disease, including systemic lupus erythematosus (SLE) and autoimmune hepatitis (AIH). On physical examination, we found malar rash, oral ulcers, slight tenderness of the sacroiliac joint, and swelling and limitation of movement in the carpal joints. There was no organomegaly.

Laboratory tests showed lymphopenia, mild Coomb’s-positive anemia, and high hepatic enzyme levels, such as alanine aminotransferase (ALT), aspartate aminotransferase (AST), and alkaline phosphatase. Serological tests were positive for serum nuclear antigen antibodies (ANA) and double-stranded DNA antibodies (anti-dsDNA) (0.868 and 28.7 IU/mL, respectively), and decreased levels of serum C4 (0.147 gr/L). Anti-smooth muscle antibody (ASMA) was greater than 1/80 and serum globulin was 3.5 g/dL. The liver needle biopsy showed bridging fibrosis and the presence of few plasma cells in portal tracts, in favor of AIH. These paraclinical results together with the clinical findings strongly suggested systemic lupus erythematosus (SLE) as the definitive diagnosis. Indeed, in this case, AIH was associated with SLE.

With the diagnosis of SLE, 30 mg/kg/day of methylprednisolone pulse was begun, with a rapid clinical improvement in arthritis, malaise, and general condition. Azathioprine was continued at the same dose as before (1 mg/kg/day). In addition, daily hydroxychloroquine sulfate, folic acid, and vitamin E were added to her medication list, to control SLE more precisely. This aggressive treatment continued for 3 days, then the methylprednisolone dose was changed to 1.5 mg/kg/day orally. This treatment continued for 2 months, after which the prednisolone dose was tapered and continued to the present.

This treatment directed against SLE resulted in both clinical and laboratory test improvements. At the 6-month follow-up, the patient had no malaise, morning stiffness, joint pain, or limitations in carpal joint range of motion. A complete blood count revealed a hemoglobin of 13.6 g/L, white blood cell count of 17,400/mm3 (diff: neutrophils 77%, lymphocytes 21%, and eosinophils 2%), and a red blood cell count of 5,250,000/mm3, showing marked improvement in lymphopenia and anemia. Biochemistry testing showed a serum creatinine of 0.8 and a normal BUN. All liver function tests were normal, except for slightly high AST of 55 IU/L. Therefore, the treatment against SLE resulted in marked improvement in SLE symptoms and signs, as well as in liver function (Table 1).

Table 1.

Follow-Up Laboratory Testing of Patient After Treatment for a Combination of SLE and AIH

Lab TestResultNormal range
CBC
RBC count5,250,000/mm33.72 - 5.30 x 1,000/mm3
Hemoglobin13.6 of 100 g/L11 - 15.5 g/L
WBC count17,400/mm3; (neutrophils 77%, lymphocytes 21%, eosinophils 2%)4,000 - 11,000 /mm3
Biochemical analysis
Serum creatinine0.8 mg/dL0.5 - 1 mg/dL
BUN12 mg/dL13 - 43 mg/dL
Liver Function Tests:
PT12 seconds12 seconds
PTT38 seconds28 - 48 seconds
ALT28 IU/LUp to 41 IU/L
AST55 IU/LUp to 31 IU/L
Alkaline phosphatase138 IU/mL64 - 306 IU/mL
Total bilirubin0.7 mg/dL0.1 - 1.2 mg/dL
Conjugated bilirubin0.2 mg/dL0.1 - 0.4 mg/dL
Albumin4.8 gr/dL3.5 - 5.5 gr/dL
Serological analysis
ESR40
ANA0.868 IU/mL< 1 IU/mL
ds DNA28.7 IU/mL< 16 IU/mL
C3135 mg/dL10 - 80 mg/dL
C414.7 mg/dL10 - 40 mg/dL
CH5099.8951 - 150
Pathological Analysis
Liver biopsyBridging fibrosis and few plasma cells in portal tracts

3. Discussion

Two types of childhood AIH are described based on seropositivity: smooth muscle antibody (SMA) and/or antinuclear antibody (ANA), which is AIH type 1, and antibodies to liver-kidney microsome type 1 (anti-LKM1), which is AIH type 2. There is a female predominance in both (7).

There is no characteristic feature that distinguishes hepatic involvement of SLE from AIH based on their clinical and biochemical profiles. Although rare, there are documented reports of liver involvement in SLE patients. The more confounding issue is that patients with AIH may be at an increased risk of developing systemic connective tissue diseases and vice versa (8). Since the treatment strategies are different in these two conditions, the challenge is whether to treat the patient as an SLE case with secondary liver involvement or as an AIH case with primary liver disease (8-13).

The diagnosis of AIH is based on laboratory and liver histology features, in addition to the exclusion of conditions that resemble AIH (14). Periportal (interface) hepatitis is the hallmark of AIH syndrome, and portal plasma cell infiltration is typical of the disorder. Although the International Autoimmune Hepatitis Group scoring system is designed for adults, it can also be used for children to support the diagnosis of AIH in the presence of periportal hepatitis (15). The diagnosis of SLE is based on the criteria defined by the American College of Rheumatology (16).

It is not possible to use the serologic criteria (such as hypergammaglobulinemia and positive tests for ANA, SMA, anti-ribonucleoprotein antibody, and anti-cardiolipin antibodies) alone in order to make the definitive diagnosis, because both AIH and SLE-associated hepatitis have features of autoimmune disorders. What can lead to a definitive diagnosis are several histological and clinical features that can differentiate AIH from SLE (17, 18). The presence of cirrhosis or periportal hepatitis, periportal piecemeal necrosis associated variably with lobular activity, and rosette formation of liver cells support the diagnosis of AIH, but do not exclude SLE. In contrast, liver histology in SLE usually shows changes attributable either to drug toxicity or non-specific liver involvement, e.g., fatty degeneration or hydropic hepatocytes (19-21).

Our patient was evaluated for hereditary (Wilson’s disease, α-1 antitrypsin deficiency, genetic hemochromatosis) and infectious (hepatitis A, B, C; CMV; EBV) liver injuries. All of the related diagnostic features were negative. The liver biopsy showed fibrosis of hepatocytes accompanied by plasma cell infiltrations. The patient met several criteria of the revised scoring system for diagnosis of AIH, including female gender, negative viral hepatitis markers, elevated serum globulins, ANA and ASMA titers, formation of liver histology, and the presence of another autoimmune disease (SLE in this case) (22). Even more interesting is that she met the American College of Rheumatology criteria for SLE as well as the criteria for AIH. She had the characteristic common SLE clinical features (photosensitivity, malar rash, arthritis, and oral ulcers) and was positive for ANA and anti-dsDNA, which are sufficient to diagnose SLE (22, 23).

We believe that our patient had AIH in association with SLE. Her first clinical and laboratory presentations were suggestive of AIH, while over the following 3 months, obvious clinical and serologic manifestations of SLE emerged, such as photosensitivity, malar rash, arthritis, and oral ulcers, as well as positive ANA and anti-dsDNA (24). By continuing her past treatment and adding new drugs, we saw rapid clinical improvement in her arthritis, malaise, and general condition, as well as her hepatitis (25, 26).

Patients with SLE have a 25% - 50% chance of developing abnormal liver tests in their lifetime. The frequency of liver dysfunction and the associated portal inflammation support the view that subclinical liver disease is a concomitant feature of SLE (27). Several previous reports indicated the manifestation of AIH in adult lupus patients. However, except for one case report indicating an overlap syndrome of AIH/SLE, there has been no article discussing AIH in association with SLE.

In conclusion, we suggest that children with liver dysfunction as an autoimmune disease, such as AIH, should be investigated for SLE since its first manifestation can be AIH. Doing so can help the physician begin the appropriate treatment sooner, saving time as well as reducing complications and improving the prognosis of SLE. Both AIH and SLE have been reported to respond rapidly to steroid therapy, and with appropriate treatment, the prognosis is generally good for both conditions. However, if left untreated, AIH can progress rapidly and lead to cirrhosis in a relatively short period of time.

References

  • 1.

    Liberal R, Grant CR, Longhi MS, Mieli-Vergani G, Vergani D. Diagnostic criteria of autoimmune hepatitis. Autoimmun Rev. 2014;13(4-5):435-40. [PubMed ID: 24418295]. https://doi.org/10.1016/j.autrev.2013.11.009.

  • 2.

    Lohse AW, Wiegard C. Diagnostic criteria for autoimmune hepatitis. Best Pract Res Clin Gastroenterol. 2011;25(6):665-71. [PubMed ID: 22117633]. https://doi.org/10.1016/j.bpg.2011.10.004.

  • 3.

    Czaja AJ, Freese DK, American Association for the Study of Liver D. Diagnosis and treatment of autoimmune hepatitis. Hepatology. 2002;36(2):479-97. [PubMed ID: 12143059]. https://doi.org/10.1053/jhep.2002.34944.

  • 4.

    Iwai M, Harada Y, Ishii M, Tanaka S, Muramatsu A, Mori T, et al. Autoimmune hepatitis in a patient with systemic lupus erythematosus. Clin Rheumatol. 2003;22(3):234-6. [PubMed ID: 14505218]. https://doi.org/10.1007/s10067-002-0689-7.

  • 5.

    Tojo J, Ohira H, Abe K, Yokokawa J, Takiguchi J, Rai T, et al. Autoimmune hepatitis accompanied by systemic lupus erythematosus. Internal Med. 2004;43(3):258-62.

  • 6.

    Chowdhary VR, Crowson CS, Poterucha JJ, Moder KG. Liver involvement in systemic lupus erythematosus: case review of 40 patients. J Rheumatol. 2008;35(11):2159-64. [PubMed ID: 18793002].

  • 7.

    West M, Jasin HE, Medhekar S, editors. The development of connective tissue diseases in patients with autoimmune hepatitis: a case series. Seminars in arthritis and rheumatism. 2006. Elsevier; p. 344-8.

  • 8.

    Bono L, Cameron JS, Hicks JA. The very long-term prognosis and complications of lupus nephritis and its treatment. QJM. 1999;92(4):211-8. [PubMed ID: 10396609].

  • 9.

    Boumpas DT, Austin H3, Fessler BJ, Balow JE, Klippel JH, Lockshin MD. Systemic lupus erythematosus: emerging concepts. Part 1: Renal, neuropsychiatric, cardiovascular, pulmonary, and hematologic disease. Ann Intern Med. 1995;122(12):940-50. [PubMed ID: 7755231].

  • 10.

    Czaja AJ. Understanding the pathogenesis of autoimmune hepatitis. Am J Gastroenterol. 2001;96(4):1224-31. [PubMed ID: 11316174]. https://doi.org/10.1111/j.1572-0241.2001.03707.x.

  • 11.

    Czaja AJ, Donaldson PT. Genetic susceptibilities for immune expression and liver cell injury in autoimmune hepatitis. Immunol Rev. 2000;174(1):250-9.

  • 12.

    Kaw R, Gota C, Bennett A, Barnes D, Calabrese L. Lupus-related hepatitis: complication of lupus or autoimmune association? Case report and review of the literature. Dig Dis Sci. 2006;51(4):813-8. [PubMed ID: 16615009]. https://doi.org/10.1007/s10620-006-3212-1.

  • 13.

    Krawitt EL. Autoimmune hepatitis. N Engl J Med. 2006;354(1):54-66. [PubMed ID: 16394302]. https://doi.org/10.1056/NEJMra050408.

  • 14.

    Alvarez F, Berg PA, Bianchi FB, Bianchi L, Burroughs AK, Cancado EL, et al. International Autoimmune Hepatitis Group Report: review of criteria for diagnosis of autoimmune hepatitis. hepatol. 1999;31(5):929-38.

  • 15.

    Ebbeson RL, Schreiber RA. Diagnosing autoimmune hepatitis in children: is the International Autoimmune Hepatitis Group scoring system useful? Clin Gastroenterol Hepatol. 2004;2(10):935-40. [PubMed ID: 15476158].

  • 16.

    Hochberg MC. Updating the American College of Rheumatology revised criteria for the classification of systemic lupus erythematosus. Arthritis Rheum. 1997;40(9):1725. [PubMed ID: 9324032]. https://doi.org/10.1002/1529-0131(199709)40:9<1725::AID-ART29>3.0.CO;2-Y.

  • 17.

    Hall S, Czaja AJ, Kaufman DK, Markowitz H, Ginsburg WW. How lupoid is lupoid hepatitis? J Rheumatol. 1986;13(1):95-8. [PubMed ID: 3701746].

  • 18.

    Leggett BA. The liver in systemic lupus erythematosus. J Gastroenterol Hepatol. 1993;8(1):84-8. [PubMed ID: 8439667].

  • 19.

    Gibson T, Myers AR. Subclinical liver disease in systemic lupus erythematosus. Rheumatology. 1980;8(5):752-9.

  • 20.

    Bach N, Thung SN, Schaffner F. The histological features of chronic hepatitis C and autoimmune chronic hepatitis: a comparative analysis. Hepatology. 1992;15(4):572-7. [PubMed ID: 1551632].

  • 21.

    Czaja AJ, Carpenter HA. Sensitivity, specificity, and predictability of biopsy interpretations in chronic hepatitis. Gastroenterology. 1993;105(6):1824-32. [PubMed ID: 8253358].

  • 22.

    Van Hoek B. The spectrum of liver disease in systemic lupus erythematosus. Neth J Med. 1996;48(6):244-53.

  • 23.

    Atsumi T, Sagawa A, Jodo S, Amasaki Y, Nakabayashi T, Ohnishi K, et al. Severe hepatic involvement without inflammatory changes in systemic lupus erythematosus: report of two cases and review of the literature. Lupus. 1995;4(3):225-8. [PubMed ID: 7655495].

  • 24.

    Usta Y, Gurakan F, Akcoren Z, Ozen S. An overlap syndrome involving autoimmune hepatitis and systemic lupus erythematosus in childhood. World J Gastroenterol. 2007;13(19):2764-7. [PubMed ID: 17569152].

  • 25.

    Apak RA, Besbas N, Ozdemir S, Ozen H, Bakkaloglu A, Saatci U. Hepatitis as the presenting symptom of childhood systemic lupus erythematosus. Turk J Pediatr. 1999;41(4):541-4. [PubMed ID: 10770126].

  • 26.

    Mieli-Vergani G, Vergani D. Autoimmune hepatitis in children: what is different from adult AIH? Semin Liver Dis. 2009;29(3):297-306. [PubMed ID: 19676002]. https://doi.org/10.1055/s-0029-1233529.

  • 27.

    El-Shabrawi MH, Farrag MI. Hepatic manifestations in juvenile systemic lupus erythematosus. Recent Pat Inflamm Allergy Drug Discov. 2014;8(1):36-40. [PubMed ID: 24383439].