P2567 - A Case of Autoimmune Hepatitis and Polymyalgia Rheumatica Secondary to COVID-19 Infection

Avneet Singh, DO, Aakhila Rameeza, DO, Alexander Garcia, DO, Ishita Dhawan, MD, Steven Peikin, MD
Cooper University Hospital, Camden, NJ

Introduction: There have been case reports highlighting autoimmune disease following COVID vaccination, but few exist of autoimmune diseases presenting after COVID infection. Here we discuss a case of a patient who developed autoimmune hepatitis (AIH) and Polymyalgia Rheumatica (PMR) after COVID infection.

Case Description/Methods: A 70-year-old male presented to his PCP for new onset pain and stiffness of the neck, shoulders, and hips and was noted to have elevated liver enzymes. Family history was negative for rheumatic and liver disease. Social history was negative for alcohol use or recent tick bites. On further questioning, the patient endorsed having symptomatic COVID infection a month before symptom onset. Initial lab values were AST 51, ALT 70, ALP 116, normal bilirubin, CRP 69, and a normal ESR. Repeat results one week later showed AST 43, ALT 92, ALP 146, elevated ESR and CRP. Further testing was negative for the hepatitis panel, soluble liver autoantibody, liver/kidney microsomal autoantibody, ANCA, and Anti smooth muscle. Anti-mitochondrial antibody (AMA) was positive with a titer of 1:40. Rheumatologic workup demonstrated a negative ANA, anti dsDNA, Sjogren's, and RF. On imaging, RUQUS revealed mild hepatomegaly and no signs of biliary ductal dilation. The patient was diagnosed with PMR and AIH by his rheumatologist and gastroenterologist, respectively. The patient was then started on prednisone 20 mg daily which resulted in the normalization of his liver enzymes and PMR symptoms.

Discussion: AIH is an inflammatory disease of the liver. It is thought that environmental triggers in a genetically predisposed patient lead to the clinical manifestation of the disease. Our patient scored a 3 on the revised original AIH score indicating possible AIH. Despite a negative ANA, the patient had normalization of his liver enzymes after starting prednisone, which was suggestive of AIH. If the patient’s liver enzymes became elevated while weaning steroids a liver biopsy would be recommended for diagnosis and possible initiation of azathioprine. An interesting feature was the positivity of AMA, which negatively impacts the AIH scoring system. AMA is the hallmark of primary biliary cirrhosis, but studies have shown that AMA can be found frequently in patients with AIH¹. As COVID becomes endemic, clinicians should be aware of the possibility of AIH being precipitated by infection.



¹Nezu S, et.al. Presence of antimitochondrial autoantibodies in patients with autoimmune hepatitis. 2006 Sep;21(9):1448-54.










Disclosures:


Avneet Singh, DO, Aakhila Rameeza, DO, Alexander Garcia, DO, Ishita Dhawan, MD, Steven Peikin, MD. P2567 - A Case of Autoimmune Hepatitis and Polymyalgia Rheumatica Secondary to COVID-19 Infection, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.