The diagnosis of autoimmune hepatitis in patients with adult‐onset still's disease

To the Editor: We read with great interest the article by Liu et al. [1] regarding the case of autoimmune hepatitis (AIH) in a patient with adult-onset Still’s disease (AOSD). We have some concerns about the diagnosis of AIH in a patient with AOSD. Liver enzyme test abnormalities are seen commonly in AOSD and it is among the minor diagnostic criteria for AOSD proposed by Yamaguchi et al. [2]. Liver dysfunction may come to attention from mild enzyme elevations to severe, even fatal liver failure which requires liver transplantation [3]. Liver involvement has been reported in many autoimmune diseases such as systemic lupus erythematosus, rheumatoid arthritis, and Sjögren’s syndrome. Although these autoimmune diseases and AIH are different entities they share similar features like female predominance, genetic susceptibility, circulating autoantibodies, and hypergammaglobulinemia [4]. According to the 1999 diagnostic criteria for AIH, many patients with these autoimmune diseases can be diagnosed definitive or probable AIH without specific liver biopsy findings [4,5]. Here in the case, the diagnosis of AIH was made with liver enzyme elevations, hypergammaglobulinemia, and positive autoantibodies. However, antinuclear antibody is actually positive in 10% of AOSD patients and in general population. Hypergammaglobulinemia is also common in AOSD [2]. Based on the current data, the coexistance of AIH and other autoimmune or systemic inflammatory diseases is possible but characteristic biopsy findings such as piecemeal necrosis, lymphoid infiltration, or rosette formation are an important part of the diagnosis. In conclusion, AIH and AOSD together in a patient is a very rare situation. Here, we think that liver enzyme abnormalities seem to be related with AOSD rather than to overlapping with AIH. In addition, large population based studies are needed to mention about treatment regimes and it is important to emphasize that the diagnosis of AIH in patients with AOSD should be based on specific biopsy findings.