Introduction: Autoimmune hepatitis (AIH) is an immune mediated destruction of hepatocytes, where immune system is hyper activated and revamped to attack the self-antigens unmasked in the liver. It usually occurs when pertinent environmental factors interact in genetically susceptible individuals. Most commonly, it is seen in females with autoimmune diseases. It is mainly classified into AIH-I and AIH-II. It can present itself as acute or chronic liver failure. Clinically, it can feign as viral hepatitis, drug-induced hepatitis, non-alcoholic steatohepatitis (NASH), thence should be
carefully discerned based on the clinical profile and pertinent autoimmune workup. Prompt diagnosis is necessary so that immunosuppression with steroids is recommended to prevent immune mediated destruction and progression to cirrhosis.

Case presentation: A 72-year old female patient presented with mildly elevated liver enzymes and liver biopsy uncovered drug-induced liver injury (DILI). She was treated with prednisone and her current medications were stopped. After her steroids were discontinued, she developed a relapse with a substantial flare-up of LFTs with histopathology unveiling AIH,and prednisolone was restarted. She also developed co-existent IVC thrombosis and thrombocytopenia.

Results: Biopsy showed portal hepatitis, interface hepatitis, bridging necrosis, epithelioid granuloma and giant cell transformation of hepatocytes. Portal tracts expanded by necroinflammatory infiltrate LFTs; AST: 218, ALT 255, bilirubin: 2.2, ALP: 202, ANA: positive (1:640), AMA & ASMA: negative. The differential diagnosis is more consistent with autoimmune like drug-induced hepatic injury vs de-novo autoimmune hepatitis.

Conclusions: This is a classic case of autoimmune hepatitis. Even though her hepatitis is precipitated by drugs (Statins), there might just serve as intercessors for unmasking the self-antigens and triggering autoimmune mediated onslaught on hepatocytes for inception of hepatitis. Moreover, cessation of steroid therapy does not a cause relapse of DILI whereas resurgence of AIH is a habitual phenomenon that materializes within few months of immunosuppression suspension.

Keywords: Autoimmune hepatitis, drug induced hepatitis, autoimmunity, self-antigens, autoantibodies, molecular mimicry, steroids, hypercoagulability, deep vein thrombosis.