Autoimmune hepatitis. routine. strong class=”kwd-title” Keywords: Mycophenolate mofetil, Autoimmune hepatitis, Azathioprine Intro Autoimmune hepatitis (AIH) is an immune-mediated chronic liver disease characterized by hepatocellular swelling, necrosis, and fibrosis, which can progress to cirrhosis and fulminant hepatic failure if left untreated . AIH has a female predominance happening in all age groups and races, and both the median and mean age of initial disease demonstration are in the forties, related to many additional autoimmune diseases. Diagnostic criteria are based on demonstration of characteristic autoantibodies, elevated immunoglobulins, and histological features of hepatitis in the absence of viral liver disease . Standard treatment of AIH includes 2-hexadecenoic acid corticosteroids only or in combination with azathioprine (AZA) that aims at the normalization of transaminase and immunoglobulin G (IgG) levels in serum which correlate with histological disease activity [1,2]. It is reported that although majority of the patients respond well to the standard therapies, about 20% of individuals do not due to either intolerance or refractory disease [2,3]. In treatment failure, alternate immunosuppressive and biological providers including mycophenolate mofetil (MMF), tacrolimus, cyclosporine and anti TNF antibodies should be considered . The patient we report here is a 48-yr old woman who was diagnosed with autoimmune hepatitis and was treated with standard therapy corticosteroids and AZA. However, she could not tolerate the side effect of AZA induced pancytopenia and pores and skin rash. MMF in combination with corticosteroid was opted as second-line treatment and the patient was able to accomplish remission with these treatments. CASE Statement A 48 year-old female was admitted to division of hepatology due to fatigue and jaundice which lasted for approximately 10 days. She also complained of anorexia, nausea and dark coloured urination. She experienced history of weighty drinking (60 g of alcohol every day) and natural tea intake (Solomons seal tea twice a week) for recent 6 months. On physical exam, icteric sclera was observed but there was neither hepatomegaly nor splenomegaly. Upon admission, the laboratory findings were as follows: alanine aminotransferase (ALT) level 472 IU/L, aspartate aminotransferase (AST) level 556 IU/L, alkaline phosphatase (ALP) 123 IU/L, total bilirubin 3.44 mg/dL, direct bilirubin 1.91 mg/dL and prothrombin time internal normalisation percentage (INR) 1.05. Viral markers including hepatitis A antibody immunoglobulin M (HAV Ab IgM), hepatitis B surface antigen (HBsAg) and hepatitis C antibody (HCV Ab) were negative. Since the patient was a middle aged female, further assessments to rule out autoimmune hepatitis were also performed. Anti-smooth muscle mass antibody (SMA) and antinuclear antibody (ANA) were positive with the ratio of 1 1:640 for ANA and IgG was increased to 1,940 mg/dL. Anti-LKM and anti-mitochondrial antibody were negative. Liver biopsy was performed and the histologic findings revealed slight portal swelling with lymphoplasmacytic, neutrophilic and eosinophilic infiltration along with minimal interface activity (Fig. 1). As the histologic findings were not standard for autoimmune hepatitis along with spontaneous sluggish decrease in AST (48 IU/L), ALT 2-hexadecenoic acid (49 IU/L) and total bilirubin (0.64 mg/dL) levels the patient was followed up while out-patient without treatment. Open in a separate window Number 1. Microscopic findings showing slight portal swelling (arrows) with lymphoplasmacytic, neutrophilic and eosinophilic infiltration along with is definitely minimal interface activity (H & E stain, 200). Two months later on, hepatitis flare recurred despite giving up alcohol and natural tea. Follow up ANA was positive with the ratio of 1 1:1,280 and IgG level was further elevated to 2,420 mg/dL (Fig. 2A, ?,B).B). Based on the lab findings and fluctuation of AST and ALT levels, analysis of autoimmune hepatitis type I had been made. She was initially prescribed with prednisolone 30 mg which was tapered to 5 mg in in 4 weeks and was managed in combination with Hoxa10 AZA 25 mg daily. The patient showed treatment response with decrease in serum AST and ALT levels along with decrease in total IgG levels after 3 months of 2-hexadecenoic acid treatment (Fig. 2A, ?,B).B). According to the autoimmune hepatitis rating system , post-treatment scores was 18, which was compatible with certain AIH. Open in a separate window Number 2. Changes in (A) serum total IgG, 2-hexadecenoic acid (B) liver enzymes and (C) total blood cell count following treatment durations. The solid arrows indicate when each medication was started. PD, prednisolone; AZA, azathioprine; AST, aspartate aminotransferase; ALT, alanine aminotransferase; WBC, white blood cells; ANC, complete neutrophil count; PLT, platelet; IgG, immunoglobulin G; ALP, alkaline phosphatase. After 3 months of maintenance treatment,.