Cytomegalovirus triggering autoimmune hepatitis: case report and literature review

Cytomegalovirus (CMV) is considered to play a role in triggering autoimmune hepatitis (AIH). It is difficult to diagnose autoimmune hepatitis because its presentation can be acute, severe, asymptomatic or chronic. Diagnosis requires multiple findings and exclusions of similar diseases. When excluding, viral etiologies are part of the differential, which in this case is CMV. If a trigger is required to set off a sequence of events leading to autoimmune hepatitis in these predisposed individuals, viruses are among the most likely candidates. In this study, a case of a 54 year-old female who presents with new onset of jaundice, associated with abdominal distension, lower extremity edema and 10 pound weight gain is reported. The autoimmune workup of the patient was significant for an elevated antibodies to nuclei (ANA) titer, anti-smooth muscle ab titer and a significant increase in immunoglobulins, specifically IgG. Interestingly, CMV Ab IgM was positive as well as CMV Ab IgG. A liver biopsy was performed which showed heavy infiltration with lymphoplasmacytic inflammatory cells, interface hepatitis, bridging necrosis and fibrosis. These pathologic and laboratory findings led us to a definitive diagnosis of AIH Type 1. In the setting of positive CMV IgG and IgM ab titers, we suggest that the trigger for AIH in this case was a preceding CMV infection. Patient improved with combination of azathioprine and corticosteroid therapy despite intermittent flares of the patient’s AIH.