Hepatitis A Infection and Autoimmune Hepatitis: Inducing or Unmasking, That‘s the Question

Abstract

A 13-year-old girl presented with a three months history of abdominal pain, jaundice, and fatigue. Three cousins developed symptoms at the same time. She sought medical help. Examination revealed HAV IgM positivity, and clinical suspicion of Hepatitis A was confirmed. After four weeks, her jaundice had not resolved, although all her three cousins who developed jaundice had experienced resolution of their symptoms. The patient visited her pediatrician. Her transaminases persisted at ALT of 633 U/L and AST of 905 U/L with direct hyperbilirubinemia. Her coagulation profile showed a slightly prolonged prothrombin time (PT 15.9 sec) and INR 1.29. Liver ultrasonography showed features of hepatitis with no evidence of obstruction. Upon presentation to the gastroenterology clinic; she was still jaundiced, with abdominal pain, fatigue, loss of appetite, and loose bowel movement. She had lost almost 4 kgs over a period of 3 months. She received no medications. On Physical examination she appeared deeply jaundiced. There was mild hepatomegaly with soft edge and no features of chronic liver dysfunction or portal hypertension were detected. Her weight and body mass index (BMI) were on the 50th centile for age. Her work-up showed negative hepatitis markers except for HAV IgG. Her immunological investigations revealed hypergammaglobulinemia and positive ASMA. She underwent liver biopsy which showed the features of autoimmune hepatitis. Patient received steroids followed by Thiopurine. On follow up, two years off treatment, the patient had no relapse.