Case Presentation: A 44-year-old African American male with medical history of hypertension presented to the emergency room for two and a half weeks of nausea without vomiting. He endorsed fatigue, weakness, anorexia, weight loss, jaundice, itching and constipation. He denied fever, night sweats, pale stools, hematochezia or abdominal pain. He reported dark urine with dysuria. He denied penile discharge, rash, renal stones or disease. He had a history of syphilis, but no other sexually transmitted infections. Personal and family history were negative for liver or autoimmune disease. He took ibuprofen but denied use of other over the counter medications, including Tylenol. His only allergy was to shellfish. He denied known exposure to ill contacts. He recently moved to Atlanta from Chicago but denied other recent travel. He admitted to use of tobacco and methamphetamine but denied use of alcohol or other illicit drugs.Vitals on presentation were significant for Pulse rate 116 beats/min and Blood pressure 133/110 mmHg. Physical examination revealed scleral icterus but abdominal examination was negative for abnormal bowel sounds, abdominal distention, tenderness or organomegaly. Other systems were unremarkable. Initial laboratory results revealed Erythrocyte sedimentation rate 84 mm/hr, C-reactive protein 1.30 mg/dL, Alanine aminotransferase 1,791 IU/L, Aspartate aminotransferase 805 U/L, Total bilirubin 4.9 mg/dL, Direct bilirubin 3.2 mg/dL, Alkaline phosphatase 333 IU/L, Gamma-glutamyl transferase 409 U/L, Activated partial thromboplastin time 48.2 seconds, Prothrombin time 13.3 seconds, and International normalized ratio 1.2. Further investigations revealed Hepatitis A IgM and IgG were positive. Remaining Hepatitis panel and HIV were negative. Immunology work up revealed positive Antinuclear antibody, Anti-smooth muscle antibody, Atypical p-ANCA and Anti-Jo-1 antibody. Ultrasound showed a compressed gallbladder concerning for intrahepatic disease. Magnetic resonance imaging showed relative normal appearance of the liver and biliary tree. The patients symptoms and transaminitis improved with conservative management.
Discussion: About 1.5 million new cases of acute hepatitis A occur worldwide annually (1). Hepatitis A virus (HAV) infection is considered a self-limiting disease, as 90% resolve in a few weeks (2). However when HAV that lasts greater than 8 weeks, a sequalae of chronic complications may occur. These include prolonged hepatitis, relapsing hepatitis, cholestatic hepatitis, and rarely induction of autoimmune hepatitis (AIH).However AIH developed in this patient with HAV after only two and a half weeks of symptoms. AIH is more common in women and the Caucasian race, however in this patient is an African American male. Though overlap between different types of AIH has been described, overlap with HAV and AIH is infrequent and not well understood. His laboratory work-up was positive for atypical p-ANCA which has been associated with the type 1 form of AIH (3). It has been theorized that in persons with this genetic predisposition are at an increased risk of developing AIH once exposed to HAV.
Conclusions: This case represents a rare incident of acute HAV infection resulting in sequelae, rather than resolution. Not only was the timeline atypical, but the overlap of AIH with an external trigger such as HAV is exceedingly uncommon. The phenomenon may be seen in those rare cases where a genetic predisposition exists and the viral infection occurs at the ‘right time’.