A Girl with Jaundice in The Emergency Department

Background: Autoimmune hepatitis (AIH) is an inflammatory liver disease, characterized by circulating autoantibodies, increased IgG levels and liver biopsy with parenchymal inflammation. In the absence of early treatment, it may progress to cirrhosis and liver failure. The acute clinical presentation with asthenia, abdominal pain, anorexia, vomiting, jaundice and headache, occurs in 50% of patients.

Case Report: Previously healthy 11-year-old girl, observed in the emergency department for fever (temperature 38.6ºC, every 6 hours), cough, rhinorrhea, frontal headache, weariness and anorexia for 8 days. No relevant personal, family or medical history. No history of recent infections. She had subicteric sclerotics, with no other relevant findings. Blood tests showed mild elevation of inflamatory parameters (WBC’S 13.160 U/L; N 75.3%; CRP 1.1 mg/dL), cytolysis (AST 433 UI, ALT 708 UI), without cholestasis (FA 264 UI, GGT 82 U/L, Total Brb 1.97mg/dL , Direct brb 0.95 mg/dL), LDH 288 U/L and normal tests for clottig time. Chest x-ray was normal. Abdominal ultrasound showed hepatosplenomegaly. The diagnosis of viral hepatitis was presumed. Due to the absence of severity criteria, she was discharged, and reassessed 24 hours later. From the additional investigation performed, the virulogical study was negative, and Wilson’s disease, alpha-1-antitrypsin deficit and hemochromatoses were excluded. Autoimmunity studies showed positive ANA, doubious anti-Dsdna antibodies and positive anti-LKM1 (LC1) antibodies. The patient was transferred to a tertiary Hospital, where underwent liver biopsy, whose result was compatible with autoimmune hepatitis. She started therapy with prednisolone and hyposaline diet, followed by azathioprine, with clinical and analytic improvement.

Conclusion: Although a large group of patients present with thypical symptoms, sometimes the ones that bring them to the ER are not the most common. Therefore, the authors intend to demonstrate the importance of a thorough physical examination and high degree of clinical suspicion, for a good diagnostic orientation.