Autoimmune hepatitis and primary biliary cholangitis overlap syndrome after COVID-19

Authors

  • Marlone Cunha-Silva Universidade Estadual de Campinas (UNICAMP), School of Medical Sciences, Centro de Diagnóstico de Doenças do Aparelho Digestivo (GASTROCENTRO), Department of Internal Medicine, Division of Gastroenterology, Campinas, SP, Brasil https://orcid.org/0000-0002-4424-6606
  • Eloy Vianey Carvalho de França Universidade Estadual de Campinas (UNICAMP), School of Medical Sciences, Centro de Diagnóstico de Doenças do Aparelho Digestivo (GASTROCENTRO), Department of Internal Medicine, Division of Gastroenterology, Campinas, SP, Brasil https://orcid.org/0000-0002-4096-5611
  • Raquel Dias Greca Universidade Estadual de Campinas (UNICAMP), School of Medical Sciences, Centro de Diagnóstico de Doenças do Aparelho Digestivo (GASTROCENTRO), Department of Internal Medicine, Division of Gastroenterology, Campinas, SP, Brasil https://orcid.org/0000-0001-5209-7228
  • Daniel Ferraz de Campos Mazo Universidade Estadual de Campinas (UNICAMP), School of Medical Sciences, Centro de Diagnóstico de Doenças do Aparelho Digestivo (GASTROCENTRO), Department of Internal Medicine, Division of Gastroenterology, Campinas, SP, Brasil https://orcid.org/0000-0002-2164-2630
  • Larissa Bastos Eloy da Costa Universidade Estadual de Campinas (UNICAMP), School of Medical Sciences, Department of Pathology, Campinas, SP, Brasil https://orcid.org/0000-0001-6932-8600
  • Priscilla Brito Sena de Moraes Universidade Estadual de Campinas (UNICAMP), School of Medical Sciences, Centro de Diagnóstico de Doenças do Aparelho Digestivo (GASTROCENTRO), Department of Internal Medicine, Division of Gastroenterology, Campinas, SP, Brasil https://orcid.org/0000-0002-0183-4678
  • Clauber Teles Veiga Universidade Estadual de Campinas (UNICAMP), School of Medical Sciences, Centro de Diagnóstico de Doenças do Aparelho Digestivo (GASTROCENTRO), Department of Internal Medicine, Division of Gastroenterology, Campinas, SP, Brasil https://orcid.org/0000-0003-3657-9280
  • Guilherme Rossi Assis-Mendonça Universidade Estadual de Campinas (UNICAMP), School of Medical Sciences, Department of Pathology, Campinas, SP, Brasil https://orcid.org/0000-0001-7644-4159
  • Ilka de Fátima Santana Ferreira Boin Universidade Estadual de Campinas (UNICAMP), School of Medical Sciences, Department of Surgery, Campinas, SP, Brasil https://orcid.org/0000-0002-1165-2149
  • Raquel Silveira Bello Stucchi Universidade Estadual de Campinas (UNICAMP), School of Medical Sciences, Department of Internal Medicine, Division of Infectious Diseases, Campinas, SP, Brasil https://orcid.org/0000-0001-9536-6299
  • Tiago Sevá-Pereira Universidade Estadual de Campinas (UNICAMP), School of Medical Sciences, Centro de Diagnóstico de Doenças do Aparelho Digestivo (GASTROCENTRO), Department of Internal Medicine, Division of Gastroenterology, Campinas, SP, Brasil https://orcid.org/0000-0002-3282-8019

DOI:

https://doi.org/10.4322/acr.2023.422

Keywords:

COVID-19, Hepatitis, Autoimmune, Liver Diseases, SARS-CoV-2

Abstract

COVID-19 is commonly associated with high serum levels of pro-inflammatory cytokines, and the post-infection status can disturb self-tolerance and trigger autoimmune responses. We are reporting a 45-year-old male who was admitted with fatigue, jaundice, elevated liver enzymes (with cholestatic pattern), and acute kidney injury two weeks after recovering from a mild SARS-CoV-2 infection. Serologies for viral hepatitis and anti-mitochondrial antibody were negative, while anti-nuclear and anti-smooth muscle antibodies were positive. There were no signs of chronic liver disease, and a magnetic resonance cholangiography showed no dilatation of biliary ducts. Histologic evaluation of the liver evidenced numerous foci of lobular necrosis without ductopenia or portal biliary reaction. Considering the autoantibody profile and histologic changes, the medical team started oral prednisone, but there was a suboptimal biochemical response in the outpatient follow-up. Two months later, a second liver biopsy was performed and revealed non-suppurative destructive chronic cholangitis, extensive areas of confluent necrosis with hepatocytes regenerating into pseudorosettes, and numerous plasma cells. According to the Paris Criteria, the patient was then diagnosed with an autoimmune hepatitis-primary biliary cholangitis overlap syndrome (AIH-PBC-OS). After adding azathioprine and ursodeoxycholic acid to the treatment, there was a satisfactory response. This is the second worldwide report of an AIH-PBC-OS triggered by COVID-19, but the first case with a negative anti-mitochondrial antibody. In this setting, histologic evaluation of the liver by an experienced pathologist is a hallmark of achieving the diagnosis and correctly treat the patient.

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Published

2023-03-10

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Section

Clinical Case Report

How to Cite

Marlone Cunha-Silva, Eloy Vianey Carvalho de França, Raquel Dias Greca, Daniel Ferraz de Campos Mazo, Larissa Bastos Eloy da Costa, Priscilla Brito Sena de Moraes, Clauber Teles Veiga, Guilherme Rossi Assis-Mendonça, Ilka de Fátima Santana Ferreira Boin, Raquel Silveira Bello Stucchi, & Tiago Sevá-Pereira. (2023). Autoimmune hepatitis and primary biliary cholangitis overlap syndrome after COVID-19. Autopsy and Case Reports, 13, e2023422. https://doi.org/10.4322/acr.2023.422