Clinical Case: A Patient with Weakness, Skin Rashes, Increased Transaminase Activity and Bilirubin Levels

Abstract

Aim: to increase physicians’ awareness of differential diagnosis of autoimmune hepatitis and diffuse connective tissue disease using a clinical case as an example. Key points. The article describes a clinical observation of a 34-year-old patient with dermatomyositis occurring against the background of atopic dermatitis and Gilbert’s syndrome, imitating autoimmune liver disease and complicated by the development of drug-induced liver injury. The complexity of diagnosis was determined by the development of skin lesions against the background of changes already present as a result of the atopic dermatitis, laboratory data (increased transaminase activity, bilirubin levels, and detection of antinuclear and anti-smooth muscle autoantibodies indicating a suspected liver disease), and the disappearance of a number of typical signs of the disease as a result of previously prescribed immunosuppressive therapy. The diagnosis was established through a thorough retrospective analysis of the clinical manifestations and anamnesis of the disease (a change in the nature of skin rashes and the predominance of increased activity of aspartate transaminase were noteworthy); the key moment for making the diagnosis was the detection of increased activity of creatine kinase and myositis-specific antibodies Jo-1. Morphological examination of liver tissue did not find signs of autoimmune hepatitis and liver fibrosis, but revealed centrilobular intracellular cholestasis and lymphohistiocytic infiltration, proliferative changes in the biliary epithelium, probably caused by drug-induced liver injury due to azathioprine intake. The issues of diagnostics and differential diagnosis of autoimmune hepatitis are considered, the strict necessity of morphological examination of the liver for diagnosis is discussed. Secondary liver injury in diffuse connective tissue disease and azathioprineinduced liver injury are analyzed. Conclusion. Differential diagnosis of elevated serum transaminases should include not only liver disease, but also muscle tissue injury. When diagnosing autoimmune hepatitis, histological examination plays a key role, and verification of the diagnosis is impossible without morphological data.

Keywords

• autoimmune liver disease
• autoimmune hepatitis
• dermatomyositis
• polymyositis
• liver damage
• druginduced liver injury
• azathioprine