Let's begin our next case.
A 54-year-old woman presents to the clinic complaining
of fatigue and a dull ache in her right abdomen.
She has a past medical
history of Grave's disease.
She takes no medications except methimazole.
Her vitals are normal.
Physical exam reveals hepatomegaly and mild
tenderness to palpation over the right upper quadrant.
Her labs show a serum AST of
1300 (U/L) and ALT of 1250 (U/L).
Alkaline phosphatase and
bilirubin are both normal.
Her viral hepatitis serologies are unremarkable
and an anti-smooth muscle antibody is positive.
So what is the most likely diagnosis?
So she has some vague symptoms with
a history of autoimmune disease.
She does have hepatomegaly and a right
upper quadrant tenderness on exam
which helps you localize
something to the liver.
And her labs are notable for a
hepatocellular injury pattern,
so a predominant elevation
in the AST and ALT.
In addition, she has this positive
anti-smooth muscle antibody.
We'll discuss what that means.
So let's now talk about
This is a condition that
affects mostly women.
It is like many other autoimmune conditions,
associated with other autoimmune diseases.
So once you have one, it's very
likely to develop another.
It's presentation can range from either
asymptomatic to acute liver failure.
The diagnosis is made by looking for a mild
to moderate elevation in your transaminases.
Because the presentation can be very
similar to other types of liver injury,
you must also rule out viral hepatitis, Wilson's
disease and alcohol or drug induced liver injury.
and the diagnosis should be confirmed
with a positive autoantibody.
So here listed here on the right
are some of the autoantibodies
that are associated with
They include an ANA, an antimitochondrial
antibody, a smooth muscle antibody
and an anti-liver-kidney-microsomal
In general, the gold standard
for diagnosis is liver biopsy
but because this is so invasive,
it is sometimes not done.
Lastly, the treatment for this condition
involves glucocorticoids or azothioprine.
So now we go back to our case.
We have a 55-year-old
woman with vague symptoms.
She does have a history of autoimmune
disease with her Grave's disease.
She has a hepatocellular pattern of
injury on her labs with hepatomegaly.
And this anti-smooth muscle antibody being
positive really helps us make the diagnosis.
Note that this antibody may be positive in autoimmune
hepatitis or primary sclerosing cholangitis
but in this whole clinical picture, we know now
that she most likely has autoimmune hepatitis.