S3674 Drug-Induced Autoimmune Liver Disease (DIAILD)

Introduction: Idiosyncratic drug-induced liver injury (DILI) affects an estimated 19 per 100,000 persons yearly and is a major cause of acute liver failure. Drug-induced autoimmune liver disease (DIAILD) is a poorly defined and under-reported liver disorder, and probably an underestimated liver disease. A small number of drug-induced liver injury (DILI) cases exhibit features typical of autoimmune hepatitis (AIH). To differentiate between true AIH triggered by drugs (DI-AIH) and immune mediated DILI still remains a challenge. Case Description/Methods: We present a 71-year-old ICU nurse with past medical history of hyperlipidemia, hypothyroidism and GERD presenting for nausea, epigastric pain, and chills. Of note, 5 days prior to onset of symptoms she received her vaccine for COVID-19. Medications that she takes at home are cimetidine, Protonix, Lipitor, Synthroid, Zofran, Vitamin A, and D supplementation. Review of systems were pertinent for mild itching, nausea, and chills. Physical exam is unremarkable except for low grade fevers, scleral icterus, and jaundice. Labs are significant for T.bili 13.5, AST 1673, ALT 2372, ALP 246, INR 1.59, ANA 1:160, AFP 169, CT abdomen/pelvis with and without contrast was unremarkable except for mild constipation. Liver biopsy was obtained that revealed submassive hepatic multilobular necrosis with confluent lytic necrosis and cholestasis involving 60-70% of the cores. Portal triads showed surrounding lymphocytic infiltrate without bile duct involvement and active interface hepatitis. active interface hepatitis, . Per pathology report the histological findings were nonspecific and a diagnosis of drug toxicity is the most compatible with given history. She was started on prednisone 40 mg daily and her liver enzymes started to improve. Discussion: In our patient we attributed the acute liver injury secondary to cimetidine from immune mediated DILI. Initially we speculated that covid 19 vaccine could have attributed to her acute hepatitis. However, at the time there were no other cases reported of Covid 19 related acute liver injury;and it could have coincidentally occurred at the same time. It will be interesting to see in the future if Covid 19 vaccine presents similar to this case. Although it is a clinical challenge to differentiate AIH and DI-AIH;it is important to keep both conditions in your differential.