Pulsed methylpresnisolone revealed autoimmune hepatitis in a patient with multiple sclerosis

Background: Intravenous methylprednisolone pulse therapy is the standard treatment for relapsing multiple sclerosis. Only three reports have described the occurrence of autoimmune hepatitis after intravenous methylprednisolone pulse therapy for multiple sclerosis. We report herein the fourth published case of methylprednisolone-induced autoimmune hepatitis. Exegesis: A Tunisian, 37-year-old woman with multiple sclerosis was treated with pulsed methylprednisolone. She did not have any history of liver disease; alcohol abuse or illicit drug use and liver tests were normal prior to treatment. Three weeks after the administration of intravenous methylprednisolone therapy, she presented with a profound elevation of liver transaminases. The viral serologies for hepatitis A, B and C, cytomegalovirus, Epstein-Barr virus and herpes simplex virus were negative. The antinuclear antibody and anti-smooth muscle antibody were positive at a titer of 1/100. Liver biopsy revealed portal lymphocytic infiltrate, interface hepatitis and fibrosis. According to the criteria of autoimmune hepatitis, the patient had a score of 16, indicating definite autoimmune hepatitis. Treatment with oral prednisone and azathioprine was initiated. Liver tests rapidly normalized. Conclusion: To the best of our knowledge, this is the fourth case of autoimmune hepatitis developed after pulsed methylprednisolone for multiple sclerosis. Administration of corticosteroids and azathioprine after pulse methylprednisolone might be effective for preventing the development of autoimmune hepatitis.