00:02
Let's begin our next case.
00:04
A 54-year-old woman presents to the clinic complaining
of fatigue and a dull ache in her right abdomen.
00:11
She has a past medical
history of Grave's disease.
00:14
She takes no medications except methimazole.
00:17
Her vitals are normal.
00:18
Physical exam reveals hepatomegaly and mild
tenderness to palpation over the right upper quadrant.
00:25
Her labs show a serum AST of
1300 (U/L) and ALT of 1250 (U/L).
00:32
Alkaline phosphatase and
bilirubin are both normal.
00:35
Her viral hepatitis serologies are unremarkable
and an anti-smooth muscle antibody is positive.
00:42
So what is the most likely diagnosis?
So she has some vague symptoms with
a history of autoimmune disease.
00:52
She does have hepatomegaly and a right
upper quadrant tenderness on exam
which helps you localize
something to the liver.
01:00
And her labs are notable for a
hepatocellular injury pattern,
so a predominant elevation
in the AST and ALT.
01:10
In addition, she has this positive
anti-smooth muscle antibody.
01:13
We'll discuss what that means.
01:17
So let's now talk about
autoimmune hepatitis.
01:21
This is a condition that
affects mostly women.
01:25
It is like many other autoimmune conditions,
associated with other autoimmune diseases.
01:31
So once you have one, it's very
likely to develop another.
01:35
It's presentation can range from either
asymptomatic to acute liver failure.
01:41
The diagnosis is made by looking for a mild
to moderate elevation in your transaminases.
01:48
Because the presentation can be very
similar to other types of liver injury,
you must also rule out viral hepatitis, Wilson's
disease and alcohol or drug induced liver injury.
02:00
and the diagnosis should be confirmed
with a positive autoantibody.
02:04
So here listed here on the right
are some of the autoantibodies
that are associated with
autoimmune hepatitis.
02:11
They include an ANA, an antimitochondrial
antibody, a smooth muscle antibody
and an anti-liver-kidney-microsomal
antibody.
02:22
In general, the gold standard
for diagnosis is liver biopsy
but because this is so invasive,
it is sometimes not done.
02:31
Lastly, the treatment for this condition
involves glucocorticoids or azothioprine.
02:39
So now we go back to our case.
02:41
We have a 55-year-old
woman with vague symptoms.
02:44
She does have a history of autoimmune
disease with her Grave's disease.
02:48
She has a hepatocellular pattern of
injury on her labs with hepatomegaly.
02:52
And this anti-smooth muscle antibody being
positive really helps us make the diagnosis.
02:58
Note that this antibody may be positive in autoimmune
hepatitis or primary sclerosing cholangitis
but in this whole clinical picture, we know now
that she most likely has autoimmune hepatitis.