[Autoimmune hepatitis: two case reports with different clinical courses - case 3/2011]

Case 1: A 46-year old female patient presented with a recently occurred icterus of unknown origin as well as dark urine and decolored stool. No diseases were found in the patient's medical history. Clinical examination showed no other findings exept from the icterus. Case 2: A 48-year old female patient was admitted to hospital with epigastric pain and icterus. Similar symptoms reoccurred regularly since several years. The patient already underwent cholecystectomy and an ERCP (endoscopic retrograde cholangiopancreaticography) that showed no pathological findings. She reported chronic pain in her finger joints and appearance of haematomas without adequate trauma.

Case 1: We found highly elevated liver enzymes and bilirubin. Ultrasound examination was unremarkable.The laboratory examination showed a negative serology for hepatitis A, B and C, marked immunoglobulin G (IgG) elevation and hypergammaglobulinaemia. Liver biopsy and analysis of autoimmune antibodies were performed showing high titers of antinuclear antibodies (ANA) and smooth muscle antibodies (SMA). Case 2: We found a considerably reduced liver function with low albumin and prothrombin time, as well as a moderate elevation of liver enzymes and a high bilirubin. Ultrasound examination revealed hepatic parenchymal changes, splenomegaly, and ascites. Oesophagogastroduodenoscopy showed oesophageal varices I°. Serology for hepatitis A, B, and C was negative. Also in this case, a marked IgG elevation and hypergammaglobulinaemia were found. Liver biopsy was performed. Autoimmune antibodies (ANA and SMA) were detectable with high titers.

In both cases, we diagnosed an autoimmune hepatitis by means of laboratory values, histological findings and detection of typical autoantibodies. Immediate therapy with high-dose prednisolone therapy was initiated (case 1: 60 mg/day; case 2: 100 mg/day), resulting in improvement of patients' condition, clinical findings and laboratory values in both cases. Case 1: The patient showed fast recovery under prednisolone and the further course was without any complications. Continuous therapy with 15 mg /day and clinical monitoring through day hospital was recommended. Case 2: We saw a slower recovery and prolonged reduced liver function with the necessity to substitute coagulation factors. Furthermore, the therapy of subsequent complications, such as surgical drainage of a haematoma, oedema, wound healing disorder and infections under prednisolone was necessary. Liver transplantation is planned if the disease progresses further.

Elevated liver enzymes should always be further investigated. Autoimmune hepatitis is a rare disease. Rapid response to immunosuppressive therapy, such as prednisolone, is characteristic. Early diagnosis and therapy are essential for the patients prognosis. Liver transplantation is indicated in advanced disease.