Daas et al. Journal of Medical Case Reports 2011, 5:233 http://www.jmedicalcasereports.com/content/5/1/233 C A S E R E P O R T JOURNAL OF MEDICAL CASE REPORTS Open Access Human immunodeficiency virus infection and autoimmune hepatitis during highly active anti-retroviral treatment: a case report and review of the literature Hanady Daas1, Riad Khatib1*, Haitham Nasser2, Farah Kamran3, Martha Higgins3 and Louis Saravolatz1 Abstract Introduction: The emergence of hepatic injury in patients with human immunodeficiency virus infection during highly active therapy presents a diagnostic dilemma. It may represent treatment side effects or autoimmune disorders, such as autoimmune hepatitis, emerging during immune restoration. Case presentation: We present the case of a 42-year-old African-American woman with human immunodeficiency virus infection who presented to our emergency department with severe abdominal pain and was found to have autoimmune hepatitis. A review of the literature revealed 12 reported cases of autoimmune hepatitis in adults with human immunodeficiency virus infection, only three of whom were diagnosed after highly active anti-retroviral treatment was initiated. All four cases (including our patient) were women, and one had a history of other autoimmune disorders. In our patient (the one patient case we are reporting), a liver biopsy revealed interface hepatitis, necrosis with lymphocytes and plasma cell infiltrates and variable degrees of fibrosis. All four cases required treatment with corticosteroids and/or other immune modulating agents and responded well. Conclusion: Our review suggests that autoimmune hepatitis is a rare disorder which usually develops in women about six to eight months after commencing highly active anti-retroviral treatment during the recovery of CD4 lymphocytes. It represents either re-emergence of a pre-existing condition that was unrecognized or a de novo manifestation during immune reconstitution. Introduction Impaired immunity in individuals with human immuno- deficiency virus (HIV) infection affects the defense mechanisms against pathogens and alters the regulation of autoimmunity [1]. This may lead to the emergence of autoimmune disorders or modification of pre-existing conditions. Several conditions may remit, such as sys- temic lupus erythematosus (SLE), while others, such as psoriasis, intensify. The development of liver disease during highly active anti-retroviral treatment (HAART) in patients with HIV infection without evidence of co- infection with hepatitis viruses poses a diagnostic * Correspondence: Riad.Khatib@stjohn.org 1Department of Internal Medicine, Division of Infectious Diseases, St John Hospital & Medical Center, 19251 Mack Avenue, Suite 340, Grosse Pointe Woods, MI 48236, USA Full list of author information is available at the end of the article dilemma. This may be due to treatment side effects or to the emergence of autoimmune disorders during immune restoration. Autoimmune hepatitis (AIH) is rare in patients with HIV infection. Additionally, hepatic involvement is unu- sual in other common autoimmune disorders. We pre- sent the case of a patient with AIH and SLE emerging de novo during HAART and review all previously reported cases of AIH in patients with HIV infection who are undergoing HAART. Case presentation A 42-year-old African-American woman who had been diagnosed with HIV infection in 1989 acquired by het- erosexual contact had a fluctuating CD4 count and a viral load secondary to non-adherence. In March 2009, she was extensively counseled on adherence to treatment © 2011 Daas et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.