Background and clinical significance: Autoimmune hepatitis (AIH) and ankylosing spondylitis (AS) are distinct immune-mediated disorders that only rarely coexist. Diagnostic interpretation becomes especially challenging when the liver biochemistry is not classically hepatocellular and the histology is unavailable. Case presentation: We report a 51-year-old man with inflammatory back pain, polyarthralgia, weight loss, fatigue, night sweats and fever. Laboratory tests showed marked systemic inflammation, anemia and a cholestatic-predominant liver profile with associated aminotransferase elevation. Imaging demonstrated bilateral sacroiliitis and syndesmophytosis. Liver workup excluded viral, obstructive, metabolic, hereditary and inflammatory bowel disease-associated cholangiopathic causes. Antinuclear antiboidies (ANA) and anti liver cyotsole 1 antiboidies (anti-LC-1) were positive, IgG was mildly elevated, magnetic resonance cholangio-pancreatography (MRCP) was negative for primary sclerosing cholangitis and the simplified AIH score was six. A liver biopsy was proposed but refused. The patient received a short course of prednisone for rheumatologic flare control, followed by nonsteroidal anti-inflammatory treatment and sulfasalazine, with normalization of liver tests during follow-up. Conclusions: This case is suggestive, but not diagnostic, of autoimmune hepatitis in a patient with ankylosing spondylitis. In the absence of histology and in the setting of a cholestatic-predominant biochemical profile, the findings may be more appropriately interpreted as an autoimmune hepatitis-like syndrome. The main teaching point is that abnormal liver tests in AS warrant structured evaluation beyond drug toxicity and viral hepatitis, particularly when autoimmune serology is positive, even in a cholestatic-predominant presentation.
Ciorba et al. (Mon,) studied this question.