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Alcoholic Hepatitis with an Unexpected Histology: A Case Report

João Pereira, Suzana Calretas, Gisela Eugenio, Maria Augusta Cipriano, Rui Santos, Armando Carvalho

(Department of Internal Medicine, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal)

Med Sci Case Rep 2016; 3:22-27

DOI: 10.12659/MSCR.897892

BACKGROUND: Alcoholic hepatitis/severe alcoholic steatohepatitis is a clinical syndrome consisting of jaundice and signs of liver failure. Its diagnosis is mostly clinical, with liver biopsy being reserved for severe or cases in which diagnosis is uncertain.
Up to 20% of alcoholic patients may have a secondary or coexisting etiology, such as autoimmune hepatitis.
 Autoimmune hepatitis is a relatively rare autoimmune disorder causing chronic liver inflammation. Clinical presentation is highly variable and diagnosis is complex, usually relying on scoring systems based in the presence of hypergammaglobulinemia, autoantibodies positivity, histologic findings, and absence of viral hepatitis.
CASE REPORT: This article describes a 44-year-old male with progressive abdominal distension, upper right abdominal pain, nonspecific malaise, and jaundice. He had a past medical history of chronic alcoholism (±80 g/day). Physical examination positive for jaundice, collateral circulation, ascites, and a mild, painful, hepatomegaly. Laboratory tests with macrocytosis, thrombocytopenia, coagulopathy, aspartate aminotransferase (AST)/alanine aminotransferase (ALT) >2, hyperbilirubinemia, positive antinuclear antibodies (ANA), high immunoglobulin-G (Ig-G) and IgA levels.
Histology was compatible with an autoimmune hepatitis.
CONCLUSIONS: The presented case highlights the diagnostic challenges of liver diseases’ diagnosis. The initial presentation and evolution were suggestive of alcoholic hepatitis. However, typical histologic characteristics for the disease, aside macrovesicular steatosis, were absent. Instead, features compatible with autoimmune hepatitis were found, leading to a diagnostic dilemma. Even though the most likely diagnosis is alcoholic hepatitis, a concomitant autoimmune hepatitis is still a theoretical possibility; therefore, a close follow-up is advisable to help confirm the diagnosis. For complex diagnostic problems, clinical suspicion and evaluation are still the most important factors in clinical practice.

Keywords: Hepatitis, Alcoholic, Hepatitis, Autoimmune, Liver Diseases

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