P4860 - A Rare Case of Infliximab Induced Autoimmune Hepatitis

Shayan Amini, MD¹, Apaar Dadlani, MBBS², Mukul Divatia, MD³, Brianna Hamilton, MD¹, Michelle Jones-Pauley, DO², Tamneet Basra, MD², Robert McFadden, MD², David W. Victor, MD², Sudha Kodali, MD, MSPH^2
1Houston Methodist-Weill Cornell Graduate School of Medical Sciences, Houston, TX; ²Houston Methodist Hospital, Houston, TX; ³University of Washington Medical Center, Seattle, WA

Introduction: Infliximab (IFX) is a monoclonal antibody that inhibits tumor necrosis factor alpha (TNF-α). Autoimmune hepatitis (AIH) is a rare but serious side-effect of IFX. We report a case of AIH in a patient on IFX for rheumatoid arthritis (RA).

Case Description/Methods: 33-year-old female with history of RA presented with jaundice and was found to have scleral icterus. She started IFX 5 months ago for RA. Labs on admission showed elevated liver tests with alanine aminotransferase (ALT) 1021 U/L, aspartate aminotransferase (AST) 787 U/L, alkaline phosphatase (ALP) 191 U/L, and total bilirubin 3.2 mg/dL. Autoimmune work-up showed elevated immunoglobulin G subclass 1 (IgG1) level of 1,651 mg/dL and normal ANA titer. Viral hepatitis work-up was negative. Hepatic ultrasound, MRCP, and HIDA scan were unremarkable. Patient was discharged with plan for outpatient follow-up. However, she returned to the hospital 3 days later for worsening jaundice. Labs showed ALT 1028 U/L, AST 1,089 UL, ALP 192 U/L, and total bilirubin 5.2 mg/dL. Repeat autoimmune work up showed elevated ANA with titer of 1:160 and IgG1 elevation at 1,784 mg/dL. Percutaneous liver biopsy revealed panlobular hepatitis, bridging necrosis in 20% parenchyma, interface hepatitis, neutrophilic bile ductular reaction without steatosis or granulomas suggestive of AIH suspected to be due to infliximab (Figure 1). She was started on prednisone 40 mg daily with improvement of her transaminases, and discharged on slow prednisone taper. Azathioprine (AZA) was added to her regimen for maintenance of remission.

Discussion: AIH is a serious side-effect of IFX therapy. The incidence of IFX-induced AIH is unclear. IFX-indued AIH occurs about 6 months after initiation of therapy marked by a hepatocellular pattern of elevated liver tests and positive autoantibodies, such as anti-nuclear (ANA), smooth muscle (SMA), and double-stranded DNA (anti-dsDNA) autoantibodies. Diagnosis of AIH is established by liver biopsy. The classic histopathologic findings of AIH include interface hepatitis with either plasma cell infiltration and/or lobular hepatitis. Treatment of drug-induced AIH involves cessation of the offending agent and addition of corticosteroids +/- AZA or mycophenolate mofetil.
In our patient, jaundice and elevation in liver tests began about 5-6 months following the first dose of IFX without any infectious or other identifiable trigger, making IFX the likely culprit of the AIH, which responded well to drug cessation and addition of steroid and AZA.



Disclosures:


Shayan Amini, MD¹, Apaar Dadlani, MBBS², Mukul Divatia, MD³, Brianna Hamilton, MD¹, Michelle Jones-Pauley, DO², Tamneet Basra, MD², Robert McFadden, MD², David W. Victor, MD², Sudha Kodali, MD, MSPH². P4860 - A Rare Case of Infliximab Induced Autoimmune Hepatitis, ACG 2024 Annual Scientific Meeting Abstracts. Philadelphia, PA: American College of Gastroenterology.