Authors:

Ferdy Junior Gatti, Carlo Soldaini, Giulia Verrusio, Benedetta Falcone, Emanuele Siani, Max Speranza, Natasha Sica, Carolina Gizzi, Antonella Santonicola, Università degli studi di Salerno.

Background and aims:

The diagnosis of autoimmune hepatitis is often very complicated. Missed diagnoses still represent a portion of the pathology, especially in the initial phase. Failure to make an initial diagnosis can have serious consequences in the patient’s prognosis, leading to cirrhosis or death due to liver failure. We are talking about a pathology with an incidence of 1 in 100,000 per year, with a greater prevalence in females. No sign or symptoms, negative serology and often serum transaminase confuse the diagnosis. We present a single case of a small elevation of transaminases which led to a diagnosis of asymptomatic celiac disease, but which was a sign of something else.

Methods:

24-year-old man with an episode of nausea, anorexia and loss of 4-5 kg in a week, which resolved spontaneously without drugs. During the episode had hyperchromic urine, yellowing of skin and eyes.
After 1 month small increase of serum transaminases x 1.5. Regular bowel function. No clinical signs.
US regular. Anti-HbsAg and HCV-Ab negative.
After another month he had highly increase of serum transaminases with AST x 27 and ALT x50 GGT x3, Total bilirubin 2.85. Negative ANA, AMA, LKM, IgA anti TTG, anti EBV, anti CMV, alpha1 anti trypsian slight increase. He performed a new serum analysis with increase of anti-TTG IgA.
He subsequently performed genetics for celiac disease and confirmed homozygous DQ2.
Performs EGDS for suspected celiac disease which documents nodularity in bulb and DII scalloping. Histological examination shows Marsh 3B.
After 150 g gluten daily intake had IgA anti TTG x 4.
A diagnosis of celiac disease is made and he started GFD with serum transaminases x 2
After 2 months with good adherence to GFD has AST x20 and ALT x 50. He denies alcohol abuse.
Negative hemochromatosis mutations. Stable weight, Regular bowel function.
We perform liver biopsy. The histological examination documents Histological Activity index acc. Knodell modified by Ishak: 7 Grading.

Results:

Diagnosis is moderately active chronic autoimmune hepatitis.
Therapy is started with prednisone 40 mg daily. With AST x10 and ALT x 20
After 15 days of therapy AST x 5 and ALT x9, therefore values halving and normal bilirubin.
Currently under follow-up in our Hospital

Conclusions:

Although the history is still unknown and the histological exam is compatible but not certain, the good response to steroid therapy is a positive factor that proves the correctness of the diagnosis.
This diagnostic difficulty leads us to always evaluate the autoimmune cause in a young patient without risk factors with a small increase in transaminases.

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