Goritsas et al. Journal of Medical Case Reports 2010, 4:9 http://www.jmedicalcasereports.com/content/4/1/9 Page 3 of 5 Figure 3 (A) Liver biopsy showing focal necrosis with neutrophils and sinusoidal reaction, hematoxylin and eosin stain ×400 magnification [R1]. (B) Liver biopsy showing Lafora body-like inclusions, hematoxylin and eosin stain ×400 magnification [R2]. hearing loss, which reports mention as present in about 10% of patients at the time of their presentation and in 40% overall during the course of their illness. The diag- nosis of Wegener’s granulomatosis was based on the clinical manifestations, imaging studies, and pathogno- monic tissue abnormalities from our patient’s lung biopsy. The diagnosis was further supported by the pre- sence of c-ANCAs, mild leukocytosis and normocytic normochromic anemia in our patient. What was surprising, however, and what makes this case worth reporting, was the coexistence of liver inflammation with a biochemical profile of severe anic- teric hepatitis at the time of Wegener’s granulomatosis diagnosis. Drug-induced liver damage was highly unli- kely because liver dysfunction and the elevation of hepa- tic enzymes persisted after the discontinuation of antibiotics. A viral hepatitis was ruled out considering Figure 4 Liver function tests in the course of time (0 on the X axis stands for the first day of admission to our department). that serologies for acute HBV, HAV and HCV infections were repeatedly negative when checked at different times, that the possibility of ischemic hepatitis in a patient without previous heart condition history was nil, and that our patient had hemodynamic stability and a perfectly normal echocardiogram. Autoimmune hepatitis (AIH) cannot be ruled out as well, since 10% of these cases may present with negative antinuclear antibodies, anti-smooth muscle antibodies, and anti-liver kidney microsomal antibodies. According to the revised criteria and scoring system by the Inter- national AIH Group [1], our patient’s AIH score was 11 +, a fact that initially made this diagnosis probable. Furthermore, ANCAs are positive in 65% to 95% of patients with AIH. However, they are usually of the perinuclear type and the histological findings from the liver biopsy in our patient were non-specific. In patients with systemic vasculitis syndromes, clinical manifestations in the liver are not frequent, although a case series notes that liver arteritis is not an infrequent finding, especially in patients with polyarteritis nodosa [2-4] or systemic lupus erythematosus [5]. The most common hepatic complications in patients with polyar- teritis nodosa as reported in the literature [3,4] are hepatic infarction or aneurysm rapture, acute liver fail- ure [6], ischemic cholangitis [7], and nodular regenera- tive hyperplasia [7,8]. Necrotizing arteritis of the liver was found in between 10% and 21% of patients with sys- temic lupus erythematosus in an autopsy series [5]. However, these findings are not related to hepatic clini- cal manifestations. In Wegener’s granulomatosis,