Appleyard et al. Journal of Medical Case Reports 2010, 4:311 http://www.jmedicalcasereports.com/content/4/1/311 The positive anti-nuclear and smooth muscle antibody results were strongly suggestive of autoimmune hepati- tis. Liver biopsy was performed and this showed fibrous expansion of portal tracts but without evidence of estab- lished necrosis. A chronic inflammatory cell infiltrate with interface hepatitis and piecemeal necrosis was evi- dent in portal areas. The histological features were con- sistent with autoimmune hepatitis (Figure 1). Initial management consisted of oral prednisolone 25 mg daily and bone protection using alendronate once weekly. Within a few weeks she had a good clinical response with resolution of jaundice and lethargy. With the exception of nitrofurantoin which was suspected of having triggered her illness, all her regular medications which had all been temporarily stopped during her investigations, were restarted. Liver biochemistry improved with bilirubin dropping from 649 to 62 μmol/ L, and alanine transaminase dropping from 1322 U/L to 118 U/L after only one month of prednisolone. The pre- dnisolone dose was subsequently reduced and azathiopr- ine was added as a steroid sparing agent. After two years she remains well with normal liver biochemistry while no longer taking prednisolone and solely taking azathioprine 150 mg daily for her chronic hepatitis. Case 2 A 42-year-old Caucasian woman, who worked as a nurse, was found to have an elevated alanine transami- nase concentration of 469 U/L (10-35), during investiga- tion of sub-fertility. The rest of her liver biochemistry including albumin, and her coagulation screen were nor- mal. She had no symptoms or signs of liver disease and her past medical history was notable only for recurrent Page 2 of 5 urinary tract infections and previous miscarriages. Her only medications were folic acid and nitrofurantoin 50 mg daily for two years. There was no history of excess alcohol intake nor ingestion of herbal remedies or sup- plements. Clinical examination was unremarkable. Further investigations revealed a very abnormal auto- immune screen including positive anti-nuclear antibo- dies at a titre of 1 in 640, smooth muscle antibodies at a titre of 1 in 320 and anti-mitochondrial antibodies at a titre of 1 in 320. Anti-Rho, extractable nuclear antibody and rheumatoid factor were also positive. IgG levels were elevated at 22.8 g/L, while IgA and IgM levels were normal. Serological testing for chronic hepatitis viruses was negative and the serum ferritin was 300 μg/ L. Liver biopsy showed marked chronic inflammation within the portal tracts and extensive fibrosis and some features of cirrhosis (Figure 2). She was treated with oral steroids at an initial dose of 40 mg of prednisolone daily. Nitrofurantoin was stopped. Since she was trying to become pregnant a bone-protecting bisphosphonate was withheld because of teratogenicity risks. Her liver biochemistry improved rapidly after a few weeks of corticosteroid medication. Plans to introduce azathioprine have been postponed while she tries to conceive. Two years after diagnosis she remains well with entirely normal liver biochemistry while taking prednisolone 7.5 mg daily. Case 3 A 74-year-old Caucasian woman with a previous history of cholecystectomy and left nephrectomy for renal carci- noma four years earlier, presented with jaundice, nausea, dark urine and pale stools. Her only medication was nitrofurantoin 100 mg daily for two years as prophylaxis against urinary tract infections. There was no history of Figure 1 Liver biopsy in Case 1: portal tract inflammation with moderate to severe chronic inflammatory cell infiltrate composed of lymphocytes with a few plasma cells (hematoxylin and eosin × 40). Figure 2 Liver biopsy in Case 2: severe chronic inflammation within portal tracts (hematoxylin and eosin × 20).