CASE PRESENTATION
A 27-years old Southeast Asian female patient was admitted on 24/02/2021
with complaints of fever and yellowish discoloration for 2 months which
were also associated with nausea, vomiting, constipation, and black
stools. She had a medical history of asthma. The patient was
non-alcoholic and was neither taking any prescription nor any
non-prescription medications. Also, she had a negative travel history to
areas endemic for hepatitis viruses and a negative family history of any
liver disease. On clinical examination, fever, hepatosplenomegaly (HSM),
and jaundice were noted. The initial laboratory examinations were
remarkable for hepatic injury with LFT revealing Aspartate
aminotransferase (AST) 2131 IU/L, Alanine aminotransferase (ALT) 1813
IU/L, Lactate dehydrogenase (LDH) 990 IU/L, Alkaline phosphatase (ALP)
263 U/L, Gamma- Glutamyltranspeptidase (GGT) 138 U/L, Albumin 3.33 g/dl,
Prothrombin time/International normalized ratio (PT/INR) and total and
direct bilirubin 6.96 mg/dl and 4.68 mg/dl respectively. USG revealed
mildly altered echotexture of the liver with smooth borders, mild HSM
with a liver span of 16 cm in the mid-clavicular line, and spleen size
of 14 cm with pericholecystic edema and mild pelvic ascites. (Figure 1)
We ruled out acute viral hepatitis due to negative Anti-HAV Ab, HBsAg,
Anti-HCV Ab, and Anti-HEV Ab. There was no Kayser-Fleischer ring seen on
slit lamp examination. Now, although the entire picture was pointing
towards autoimmune hepatitis, but serology was negative for the classic
autoantibodies including ANA (via immunofluorescences), Anti-SM Ab,
Anti-LKM-1 Ab, and also a negative Immuno 17 report. This raised
suspicion of seronegative AIH. The patient was also admitted on
29/01/2021 with similar complaints of pyrexia of unknown origin and
jaundice but responded to symptomatic treatment. However, she relapsed
now. Due to a high clinical suspicion, the patient was advised to have a
liver biopsy to confirm the diagnosis, but the patient’s unstable
condition didn’t permit a biopsy. Still, she was diagnosed with
seronegative AIH due to her clinical picture and prescribed
methylprednisone (MPS) to which the patient responded with a visible
improvement of her LFT as mentioned in Table 1.
This improvement in the clinical picture following steroids’
administration confirmed the diagnosis of seronegative AIH in our
patient.