A typical autoimmune hepatitis (AIH) case following Covid‐19 mRNA vaccination. More than a coincidence?

Abstract

Recently in the Liver International, three patients1, 2 with AIH during COVID-19 were reported. Τhere is also increasing evidence that vaccination for SARS-CoV-2 may induce autoimmunity.3, 4 Here, we present a case of histologically confirmed AIH after mRNA vaccination against SARS-CoV-2. A 52-years-old Caucasian woman with no medication history or alcohol abuse and normal liver blood tests during previous periodical checkup, received her 1st dose of the Moderna vaccine on 11th of May 2021. Two weeks later she presented malaise, jaundice and abnormal liver blood tests AST: 350 U/L (5-34 U/L), ALT: 936 U/L (0-55 U/L), γGT: 810 U/L (9-36 U/L), ALP: 169 U/L (40-150 U/L), T.Bil: 9.06 mg/dL (0.2-1.2 mg/dL), D.Bil: 5.5 mg/dL (0-0.5 mg/dL), CRP: 1.25 mg/dL (<1.0 mg/dL), ESR: 25 mm/h. Antinuclear antibodies (1/320) and anti-smooth muscle antibody (ASMA) were positive. IgG levels were elevated at 2396 mg/dL (700-1600 mg/dL). Serology for hepatitis A, B, C, E virus, CMV and EBV were negative. Abdominal ultrasound and MRCP were normal. Liver histology (9 portal tracks) showed moderate to severe inflammatory infiltration consisting of lymphocytes, plasmatocytes, histiocytes, few eosinophiles and neutrophiles with the presence of mild periportal hepatitis. Mild lobular inflammation, apoptotic bodies, hepatocytes with feathery degeneration of the cytoplasm and rosette formation were observed (Figure 1). The patient started prednisolone 50 mg per os daily followed by azathioprine 50 mg daily, with gradual improvement of the symptoms and the laboratory tests. The patient did not have any known background of autoimmunity. The clinical and laboratory data were compatible with typical AIH while the simplified AIH score proved a definite AIH case. Many questions arise concerning the rationale of this AIH case. Is this a typical AIH triggered by a vaccine or did the vaccine induce the autoimmunity? On the other hand, a vaccine related DILI with autoimmune features cannot be excluded. Despite the fact that AIH can be triggered by vaccination (hepatitis A–B, yellow fever),5 one might argue whether this case is a new disease entity related to the specific mRNA vaccine. Further research exploring the cross-reactivity of the Coronavirus proteins with human ones is needed. We have to clarify that this is a rare case of a vaccine-induced autoimmune disease, which can be controlled with the appropriate management and close monitoring. Despite the need of increased vigilance for possible autoimmune reactivity after vaccination this should not be considered a cause of no vaccination behaviour since all the reported similar cases had a good outcome. None. The data that support the findings of this study are available from the corresponding author upon reasonable request.

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