[Elevated liver enzymes in rheumatoid arthritis : differential diagnostic considerations based on a case report]

Elevated liver enzymes in patients with rheumatoid arthritis may have various causes. These can range from the rheumatic disease itself, the anti-rheumatic medication or be the manifestation of an associated autoimmune disease. We present the case of a 19-year-old female with known seropositive rheumatoid arthritis who developed severe liver damage after 9 months of anti-rheumatic therapy with leflunomide and adalimumab. Both drugs were stopped. In addition to the underlying disease and the specific anti-rheumatic drugs, a temporary therapy with flucloxacillin as well as an association with newly diagnosed celiac disease had to be considered as possible causes of elevated liver enzymes. Following repeated liver biopsy, autoimmune hepatitis was assumed and prednisolone and azathioprine were initiated. Elevated liver enzymes and bilirubin rapidly returned to normal values.