A36 Infliximab Induced Autoimmune Hepatitis: Two Cases with Different Outcome (original) (raw)

Background: Inhibitors of tumor necrosis factor alpha (anti-TNF alpha) are an important component of treatment of number of inflammatory conditions. However, multiple adverse effects have been identified with the growing use of these agents and the prolonged follow up. Autoimmunity has been linked to Infliximab. This includes Lupus, Vasculitis and interstitial lung disease. There are a few reports in the literature regarding infliximab induced autoimmune hepatitis. We report an interesting case of infliximab-induced autoimmune hepatitis that was successfully treated by discontinuation of infliximab. On the other hand, Infliximab induced autoimmune hepatitis can be quite dramatic. Withdrawal of infliximab and even steroid treatment might not be sufficient to reverse the process and patients might eventually need liver transplant. We are reporting a second unfortunate case where infliximab induced autoimmune hepatitis leads to fulminant liver failure requiring liver transplant. Aims: To increase the awareness a potential side effect and improve early identification and treatment. Methods: Case report and review of the literature. Results: A 57 years old lady with a 1-year history of Crohn's disease, maintained on Infliximab, started 4 months prior to her presentation. She was referred to our hepatology clinic because of elevated liver enzymes. The patient was a symptomatic. Her investigations showed elevated liver enzymes as well as positive autoimmune markers. A liver biopsy was done. The biopsy Excluded element of chronicity, and the acute insult was related to Infliximab. Inflixamab was stopped and the patient was started on Vidolizumab. Her liver enzymes came down to a normal level. The second case is a 69 years old lady with a 13 years history of fistulizing Crohn's disease with multiple small bowel resections and fistulectomy. The patient was started on Infliximab 3 months prior to her presentation and than she was noticed to be jaundiced. Subsequently, a blood work showed elevated liver enzymes with positive autoimmune markers. Imaging showed no intra or extra hepatic obstructions.During her hospitalization she showed further elevation of liver enzymes with deterioration of synthetic liver function. Additionally, The patient developed hepatorenal syndrome and encephalopathy. She was started on prednisone 20 mg daily without significant improvement. Liver biopsy was done and showed no evidence of chronicity with evidence of prominent plasma cells infiltrate suggestive of autoimmune hepatitis. Our transplant team evaluated the patient and a she underwent a liver transplant. Conclusions: Early recognition of this entity prevents further sequela and unnecessary investigations. The presentation of infliximab induced autoimmune hepatitis can range from mild elevation of liver enzyme that can respond to discontinuation of Infliximab to a fulminant liver failure.