Diclofenac-Induced Post Infantile Giant Cell Hepatitis

Abstract

INTRODUCTION: Post-infantile Giant Cell Hepatitis (PIGCH) is a rare type of autoimmune hepatitis (AIH) characterized by an idiosyncratic response to liver injury from various causes in which liver cells respond to insult by rapid proliferation and without the appropriate cellular division, leading to the formation of the multi-nucleated giant cells. We encountered a case of Diclofenac induced PIGCH in a patient with untreated seropositive rheumatoid arthritis. To the best of our knowledge, this is first such case reported in the literature. CASE PRESENTATION: A 48-year-old Hispanic woman with type II diabetes and rheumatoid arthritis, not on DMARDs presented with acute onset jaundice and right upper quadrant pain. She was taking 50mg of Diclofenac, 2 pills daily for the past 3 months and unknown quantity of garlic tablets. Workup for hepatitis including infectious and toxic etiologies were ruled out. Serum IgG levels were elevated with increased globuin gap, and positive ANA titer of 640, anti-smooth muscle cell antibodies elevated at 41 units (moderate to strong positive > 30 units). Liver biopsy demonstrated submassive necrosis in the setting of post-infantile giant cell hepatitis. The differential diagnoses included idiopathic autoimmune hepatitis, viral or drug induced injury. Our diagnosis was drug induced autoimmune liver disease (DIALD), the etiology is likely due to Diclofenac given temporal relationship of drug intake and symptom onset, as well as a calculated Roussel Uclaf Causality Assessment Method (RUCAM) score of 6, signifying probable drug-induced liver disease. Patient was started on Prednisone and Azathioprine with complete resolution of clinical and laboratory findings within 5 months. DISCUSSION: The outcome of PIGCH is unpredictable, usually adopts a fulminant course leading to cirrhosis within months, however, a more benign course has also been described. PIGCH is triggered by three primary etiologies: drugs, infection, and autoimmune liver injury. This case highlights that giant cell hepatitis is a multifactorial condition that can be precipitated by drug use in the setting of autoimmune phenotype. Garlic and garlic extracts, through their antioxidant activities, have been reported to provide protection against free radical damage in the body. The innocuous course of PIGCH in our patient could possibly be due to concurrent consumption of garlic tablets. Further research is needed in this area.