United States

Title: Effective Management of Pediatric Autoimmune Neuropsychiatric Disorders
Associated with Streptococcal Infections (PANDAS) in a 15-Year-Old Girl: A Case Report
Authors: Varsha Kakani MBBS, Dwija Rajguru, Meet Singh MBBS
Keywords: Neuropsychiatric symptoms, Streptococcal infection, Antibiotics, Corticosteroids, SSRI
Background &amp; Introduction: Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS) is characterized by sudden onset obsessive-compulsive behavior, tics, and various behavioral issues in children with a history of streptococcal infections. Symptoms include personality changes, cognitive decline, motor disturbances, sensory sensitivity, behavioral changes, and psychosis. Linked to repeated streptococcal infections, PANDAS affects children aged 3 to 12 years, with an incidence of 1 per thousand. The disorder results from molecular mimicry, leading to the production of cross-reactive antibodies that can cross the blood-brain barrier and bind to neuronal antigens like lysoganglioside, dopamine receptors, and CAMK II (calcium/calmodulin-dependent protein kinase II), particularly in the basal ganglia, triggering rapid onset obsessive-compulsive symptoms. Diagnosis and followup relies on elevated Anti-streptolysin O [ASO] or Anti-DNAse B titers. Treatment involves antibiotics, corticosteroids, and SSRIs to prevent persistent symptoms into adulthood.
Case Report: A 15-year-old Puerto Rican girl presented with altered behavior over three weeks, including visual, auditory, and tactile hallucinations, discomfort from seeing numbers shake in class, nausea when looking at certain numbers and letters, and distortions in her reflection. She also experienced eye blinking tics, crawling sensations, significant anxiety, social isolation, and prolonged showers. Despite these symptoms, her sleep and appetite were undisturbed. Her father reported multiple streptococcal throat infections, decreasing after a tonsillectomy at age 10. Recent sore throat symptoms resolved with over-the-counter analgesics.
Elevated Anti-DNAse B antibodies (1070 U/ml) and ASO titers (342.1 IU/ml) suggested PANDAS. She was initially treated with Clindamycin due to a penicillin allergy but showed no improvement. The treatment was then switched to Azithromycin, which led to partial improvement. Subsequent treatment with methylprednisolone, naproxen, and sertraline significantly reduced her symptoms within one week, allowing her to refocus on schoolwork. Follow-up ASO titers decreased to 306.8 U/ml.
Discussion: This case highlights the diagnostic challenges and therapeutic response in suspected PANDAS. The acute onset of neuropsychiatric symptoms, along with elevated streptococcal antibodies, supported the diagnosis. Initial antibiotics provided partial relief, but significant improvement was achieved with corticosteroids and SSRIs, underscoring the benefit of integrated treatment.
Conclusion: PANDAS should be considered in pediatric patients with acute neuropsychiatric symptoms and a history of streptococcal infections. Early recognition and combined antibiotic, corticosteroid, and
SSRI therapy can effectively manage PANDAS symptoms.


AMA Research Challenge 2024 

Effective Management of Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (Pandas) in a 15-year-old girl: A Case Report

Title: Effective Management of Pediatric Autoimmune Neuropsychiatric Disorders
Associated with Streptococcal Infections (PANDAS) in a 15-Year-Old Girl: A Case Report
Authors: Varsha Kakani MBBS, Dwija Rajguru, Meet Singh MBBS
Keywords: Neuropsychiatric symptoms, Streptococcal infection, Antibiotics, Corticosteroids, SSRI
Background & Introduction: Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS) is characterized by sudden onset obsessive-compulsive behavior, tics, and various behavioral issues in children with a history of streptococcal infections. Symptoms include personality changes, cognitive decline, motor disturbances, sensory sensitivity, behavioral changes, and psychosis. Linked to repeated streptococcal infections, PANDAS affects children aged 3 to 12 years, with an incidence of 1 per thousand. The disorder results from molecular mimicry, leading to the production of cross-reactive antibodies that can cross the blood-brain barrier and bind to neuronal antigens like lysoganglioside, dopamine receptors, and CAMK II (calcium/calmodulin-dependent protein kinase II), particularly in the basal ganglia, triggering rapid onset obsessive-compulsive symptoms. Diagnosis and followup relies on elevated Anti-streptolysin O [ASO] or Anti-DNAse B titers. Treatment involves antibiotics, corticosteroids, and SSRIs to prevent persistent symptoms into adulthood.
Case Report: A 15-year-old Puerto Rican girl presented with altered behavior over three weeks, including visual, auditory, and tactile hallucinations, discomfort from seeing numbers shake in class, nausea when looking at certain numbers and letters, and distortions in her reflection. She also experienced eye blinking tics, crawling sensations, significant anxiety, social isolation, and prolonged showers. Despite these symptoms, her sleep and appetite were undisturbed. Her father reported multiple streptococcal throat infections, decreasing after a tonsillectomy at age 10. Recent sore throat symptoms resolved with over-the-counter analgesics.
Elevated Anti-DNAse B antibodies (1070 U/ml) and ASO titers (342.1 IU/ml) suggested PANDAS. She was initially treated with Clindamycin due to a penicillin allergy but showed no improvement. The treatment was then switched to Azithromycin, which led to partial improvement. Subsequent treatment with methylprednisolone, naproxen, and sertraline significantly reduced her symptoms within one week, allowing her to refocus on schoolwork. Follow-up ASO titers decreased to 306.8 U/ml.
Discussion: This case highlights the diagnostic challenges and therapeutic response in suspected PANDAS. The acute onset of neuropsychiatric symptoms, along with elevated streptococcal antibodies, supported the diagnosis. Initial antibiotics provided partial relief, but significant improvement was achieved with corticosteroids and SSRIs, underscoring the benefit of integrated treatment.
Conclusion: PANDAS should be considered in pediatric patients with acute neuropsychiatric symptoms and a history of streptococcal infections. Early recognition and combined antibiotic, corticosteroid, and
SSRI therapy can effectively manage PANDAS symptoms.


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Background :
Sickle cell disease (SCD) is the most common hemoglobin anomaly in the United States and has numerous complications. Intravenous (IV ) fluid hydration is a principal element in the management of pain crisis. Intravenous hydration is commonly used in the treatment of vasoocclusive crises , as dehydration promotes erythrocyte sickling. Potential complications of continuous fluid replenishment include weight gain, heart failure, pulmonary edema and lower extremity edema.

Case Presentation :
This is a case of a 25-year-old female with a past history of SCD who was admitted for an acute pain crisis. Her symptoms of generalized myopathy was precipitated after drinking 2 bottles of beer. On presentation, her vitals were T 97.5 F ,BP 104/75, HR 124, RR 27, SpO2 100% on room air. Blood alcohol level was 180, reticulocyte count 15.6, urine screen was positive for alcohol and THC, hemoglobin and hematocrit were 8.9 & 25.6. She received a bolus of normal saline (NS)
and was started on D5W 0.3%NS. Her pain was controlled with a multimodal approach using NSAIDS, heat patches, Duloxetine and a Hydromorphone PCA pump. Due to poor oral intake, she continued to be on maintenance IV fluids. On day 7 of admission, the patient reported chest pain with BP 88/53,HR 109, RR 28, sPO2 88%at room air. Chest x-ray revealed bilateral perihilar and basilar alveolar opacities with obscured hemidiaphragms, costophrenic sulci and portions of heart borders, which were new findings. Troponins drawn eight hours apart read 345> 408>160 respectively. The patient was started on Levofloxacin due to allergies to other antibiotics. An exchange transfusion improved her symptoms.

Discussion :
Alcohol is a diuretic that can worsen volume status and cause dehydration thereby promoting sickle cell clumping and triggering a crisis. ACS is a form of acute lung injury defined by new pulmonary findings on chest x-ray combined with ≥ 1 manifestation such as cough, fever, chest pain, tachypnea, dyspnea, sputum production, or new-onset hypoxia. The vital signs and new radiologic findings due to volume overload IV fluids were consistent with ACS. Prolonged periods and insufficient monitoring of hydration status could lead to complications of
hyperhydration that could present as an ACS. There are currently no guidelines for fluid replacement in patients with SCD. Taking this into account , the provider should guide clinical decision on choice and duration hydration. Improving the awareness of this potential effect among health care providers would also prevent complications.

Iatrogenic Acute Chest Syndrome in a Patient with Sickle Cell Disease.

Background: Non-alcoholic Fatty Liver Disease (NAFLD), recently renamed Metabolic dysfunction-associated Steatotic Liver Disease (MASLD), is the leading cause of chronic liver disease, contributing significantly to liver-related morbidity and mortality. Evidence indicates that lean individuals exhibit a higher rate of disease progression, liver fibrosis, cardiovascular morbidity, and all-cause mortality in advanced stages compared to obese individuals. Genetic factors significantly influence the prevalence of MASLD. This clinical scenario highlights a unique case of a lean patient with metabolic syndrome and hepatic steatosis, absent hepatic lesions.
Case Presentation: An Asian female in her mid-50s, weighing 124 lb, visited her Primary Care Physician (PCP) with complaints of right upper quadrant abdominal pain and bloating after consuming a high-fat diet. She had no vomiting or diarrhea history but reported occasional constipation and elevated systolic blood pressure. Laboratory results indicated borderline elevated HbA1C, high triglycerides, and cholesterol levels. Comprehensive testing, including SIBO, stool tests, H. pylori, anti-HbC, and pancreatic elastase 1, alongside upper and lower GI endoscopy, ultrasonography with elastography, abdominal X-ray, and CT scan, were conducted. Initially misdiagnosed with Functional Bowel Disorder, the patient received treatments for elevated triglycerides, cholesterol, blood glucose, and gastrointestinal (GI) symptoms. After four years of persistent GI symptoms, further diagnostics led to a diagnosis of Lean MASLD with hepatic steatosis but no hepatic lesions.
Discussion This case underscores that individuals with a normal BMI can still have abnormal metabolism, hepatic steatosis, and steatohepatitis. Preventing disease progression in such patients is crucial. Despite the rising prevalence and burden of MASLD, effective pharmacotherapy remains limited and evolving. Current treatments focus on addressing metabolic syndrome and promoting weight loss. Evidence supports a weight loss regimen involving a low-carbohydrate, hypocaloric diet aiming for a 30% calorie reduction, or 1200–1500 kcal/day, or a 500–1000 kcal/day reduction from baseline. For lean patients, the goal should be a hypocaloric diet combined with aerobic exercise. The case highlights an opportunity to enhance PCP awareness regarding MASLD, given the initial misdiagnosis of Functional Bowel Disorder. As PCPs and endocrinologists often serve as the first point of contact for MASLD patients in the US, they need to be well-versed in clinical care pathways and evidence-based guidelines to ensure accurate screening, diagnosis, initial management, and timely referrals for at-risk patients.





“Lean and at Risk” for Nonalcoholic Fatty Liver Disease: Case Scenario Urging Crucial Attention

Background:
Acquired hemophilia A (AHA) is an autoimmune disease characterized by the development of autoantibodies against coagulation factor VIII (FVIII). AHA most commonly occurs spontaneously in older adults, but can be triggered by malignancy, autoimmune disease, pregnancy, infection, and drugs, particularly antibiotics. We report a rare case of AHA diagnosed in the setting of GI bleeding refractory to numerous endoscopic treatments.

Case Presentation:
A 71-year-old man with coronary artery disease who was initially hospitalized for cellulitis that did not respond to multiple prolonged courses of outpatient antibiotics developed a GI bleed. On admission, he was placed on cefazolin and developed hematemesis 4 days later. Endoscopy identified an oozing gastroesophageal junction (GEJ) ulceration with a visible blood vessel. It was treated with epinephrine injections, hemostatic clips, and spray. The patient was readmitted twice shortly after discharge for recurrent bleeding, first for melena and then for hemorrhagic shock. He received four total endoscopies finding active bleeding at the GEJ, all with successful procedural hemostasis. Coagulopathy workup revealed a persistently elevated prothrombin time, with only partial correction in mixing studies. Further testing identified the specific FVIII inhibitor, quantified its high titer of 71 Besthesda Units, and confirmed extremely low FVIII activity (<1%) diagnostic for an acquired FVIII deficiency. Sulfasalazine was considered the most likely inducer. The bleeding stopped after fresh frozen plasma transfusions, and he was discharged home on corticosteroids, with plans to start rituximab.

Discussion:
This case underscores the consideration of coagulopathies as possible contributors to refractory anemia and GI bleeding. Recent antibiotics should increase suspicion of AHA, even without a prior history of abnormal coagulation. This approach can lead to timely and appropriate treatment interventions, such as immunosuppressive therapy and FVIII replacement, ultimately improving patient outcomes. Despite its rarity, awareness and suspicion of AHA can significantly impact the management and prognosis of affected patients.

Acquired Hemophilia A: A Rare Case of Persistent Peptic Ulcer Bleeding Despite Multiple Endoscopic Treatments


Background
Small intestinal bacterial overgrowth (SIBO) is a condition that is defined by an overgrowth of normal flora in the small intestinal, causing symptoms similar to irritable bowel disease, such as abdominal pain, diarrhea, and frequent stools. Altered flora can arise from dysmotility, altered anatomy, such as surgery, or hypochlorhydria. A known condition that is associated with SIBO is auto-brewery syndrome, in that the intestinal flora metabolize carbohydrates into ethanol, which will, then, intoxicate the patient. However, alcohol abuse is a common condition worldwide. Patients that are addicted to alcohol often have financial, social, and interpersonal strain, and those patients often go to great lengths to hide their alcohol abuse to their spouses and family, often involving elaborate lies and trickery. Moreover, a patient that has a history of alcohol abuse is at greater risk of relapse following abstinence from alcohol.
Case Presentation
We present a case of a 48-year-old patient with a medical history of SIBO who is presenting to the emergency department acutely intoxicated. The patient is accompanied by his wife. She states that since he has been diagnosed with SIBO, he often experiences multiple “episodes” per month where he appears intoxicated, and that it is controlled by a specific diet that they have worked to develop. She endorses that he has a history of alcohol abuse, and that he has abstained from alcohol for about 2 years, with no possibility of the patient relapsing as they both work from home and the majority of their time together. Labs were significant for a blood alcohol level (BAC) of 0.47. He was then admitted to the hospital, and his BAC was trended, which showed a linear decrease of .02 per hour. The patient was not restricted in his diet and was seen to eat carbohydrates, with no increase in BAC, thus ruling out auto-brewery syndrome, leaving a relapse of alcohol abuse as his final diagnosis.
Discussion
This case provides an intricate display of SIBO, auto-brewery, and chronic alcohol abuse disorder. The endogenous production of ethanol by intestinal microorganisms results in intoxication symptoms. The differentiation of auto-brewery and alcohol use is crucial as management includes carbohydrate-restricted diet, antibiotics, and cessation of alcohol consumption. Psychosocial elements of this case highlight the interdepartmental teamwork from medical doctors, nutritionists, and psychosocial personnel and support systems.

Alcohol Abuse or Auto-Brewery A Case of Complicated SIBO and Addiction

Background
Emphysematous gastritis is a rare and lethal disease characterized by air within the gastric wall, caused by gas forming microorganisms such as Escherichia coli, streptococcus species, and clostridium species, to name a few. Even when identified early, it has a mortality rate of 60%. Here we present a rare case of emphysematous gastritis that developed while the patient was admitted to the hospital for an unrelated reason.

Case Presentation
A 62-year-old male with past medical history of type 2 diabetes mellitus and osteoarthritis with long-term naproxen use presented to the hospital for an elective left total knee arthroplasty, which he underwent successfully. On postoperative day 3, patient developed dyspnea and severe abdominal pain accompanied by nausea and multiple episodes of nonbilious emesis. On exam, abdomen was moderately distended with guarding and diffuse tenderness to palpation, but bowel sounds were preserved. Lab studies remarkable for white blood cell count 13.7x103/L, hemoglobin 9.7 g/dL, and lactic acid 1.5 mEq/L. An emergent CT scan with IV contrast showed evidence of emphysematous gastritis with portal venous gas. Due to the high risk of iatrogenic perforation from endoscopy, he was managed non-operatively with IV fluids, pantoprazole, antiemetics, and antibiotic coverage with vancomycin and piperacillin-tazobactam. Within 48 hours, the patient’s symptoms resolved, blood cultures were negative, and he was discharged shortly afterwards to finish a 14-day course of levofloxacin and metronidazole.

Discussion
It is often challenging to distinguish between emphysematous gastritis and gastric emphysema. Gastric emphysema is an asymptomatic non-infectious process that is associated with mechanical disruption of the gastric wall (i.e., surgery, endoscopy or nasogastric tube placement). In contrast, emphysematous gastritis is a life-threatening condition often caused by a bacterial infection that arises locally or spreads hematogenously from a distant focus. In our case, the major risk factors were diabetes mellitus and chronic nonsteroidal anti-inflammatory drug use, creating a favorable environment for bacterial invasion. Although the mainstay of treatment is supportive, emphysematous gastritis can lead to severe septic shock, gastric perforation, hemorrhage, or gastric wall necrosis if not identified promptly. In such cases, emergent surgical intervention is warranted.


Emphysematous Gastritis: A Rare but Critical Gastrointestinal Condition


Background
Hydatid cyst disease is amongst the most common zoonotic parasitic manifestations, caused by Echinococcus granulosus where humans act as an accidental host. Hydatid cyst of anterior wall (1-4%) has been observed in a few patients without primary involvement of the liver. 

Case Presentation
A 33 year old, young male presented with on and off dull aching abdominal pain with fever for 5 years but was misdiagnosed as anterior abdominal wall haematoma. The only significant history was possession of an unvaccinated stray dog. Physical examination revealed a cystic, tender swelling around 5x10 cm in the region of right hypochondrium to right lumbar region. Abdominal Contrast enhanced computed tomography revealed a slightly thick walled cystic appearing lesion 6.1x 9.6 x 5.5 cm suggesting a focal discontinuity of its antero-medial wall with surrounding relatively ill- defined hypo-dense collection seen partly insulating in the inter-muscular planes, suggesting a partly ruptured hydatid cyst without any evidence of any intraperitoneal extension. Serology of Hydatid cyst was positive. Patient was prophylactically started on Albendazole until surgical exploration. During surgery, cystic mass was found adherent to anterior abdominal wall muscles without any parietal peritoneum adhesions. En-masse excision was done from subcutaneous planes, keeping the cyst wall intact. The point of rupture was identified and the cyst fluid and daughter cysts suctioned with minimal spill to vicinity and irrigation was performed with hypertonic saline. Cetrimide soaked gauze was placed at operative site for 10 minutes. Gross and Histopathology examination confirmed Hydatid cyst. Patient was advised to take oral Albendazole and Praziquantel for 6 months. Patient had an uneventful post-operative course till 6 months follow up.

Discussion 
Echinococcus granulosus, the smallest of all tapeworms, a zoonotic cestode with humans being an accidental host infected by ingestion or direct contact with infected canines. The clinical course and symptoms of cystic hydatidosis depend upon site of infection, size of cysts and the pressure symptoms caused by enlargement of the cysts. Careful history taking, thorough examination along with the use of radiological and serological investigations aid in reaching a confirmatory diagnosis of the disease. Treatment modalities comprise of anti- parasitic drugs, PAIR (puncture-aspirate-inject- reaspirate) and surgery. Prevention of cystic echinococcosis includes public education, deworming of dogs and slaughter house hygiene. Early and prompt diagnosis with timely management is the need of the hour to decrease the global burden of the disease. 


Hydatid Cyst of Anterior Abdominal Wall: A Case Report

A 56-year-old woman with a past medical history of alcohol-associated cirrhosis presented for hematochezia. She was hypotensive. A computed tomography (CT) angiogram scan of the abdomen and pelvis revealed a conglomeration of severe right lower quadrant (RLQ) varices extending to the right colon wall. The prevalence of colonic varices (CV) is likely underestimated. While gastrointestinal bleeding from colonic varices is rare, there is a potential risk of death in severe cases. Currently, there are no specific guidelines for managing colonic varices. The management choice is based on the etiology, severity of bleeding, and distribution of the varices.

Massive Lower Gastrointestinal Bleeding From Colonic Varices In a Patient With Cirrhosis

Introduction: Diverticulitis is a well-studied colorectal disease that is mostly managed conservatively. Severe diverticulitis may progress to pericolic abscess or perforation when not caught early. Patients with diverticulitis are predisposed to hepatic abscesses via seeding through the portal system. In rare cases such as ours, the hepatic abscesses lead to a hepatopulmonary fistula, causing recurrent symptomatic pleural effusions. 

Case Description: A 61-year-old male with history of right sided diverticulitis presented to the emergency department with a 2-week history of worsening abdominal pain and a 2-day history of chest pain and dyspnea. On physical exam, he was diaphoretic, tachycardic, and hypotensive. Chest X-Ray revealed a moderate sized right sided pleural effusion. CT scan of Abdomen Pelvis with IV Contrast was indicative of multiple large air fluid collections surrounding the liver with one collection near the dome of the liver that fistulized to the right lower lobe of the lung. There was also notable wall thickening of the cecum and ascending colon with surrounding inflammation, suggesting diverticulitis. Due to his hemodynamic status, sepsis protocol was initiated, including treatment with broad spectrum IV antibiotics. CT guided drainage catheter was placed within the liver abscess and intracatheter contrast confirmed a fistulous tract into the right lower lobe of the lung. A chest tube was placed to drain the pleural effusion, and fluid culture was positive for S. Anginosus, B. Fragillis, and Prevotella, indicating a clear abdominal source. The patient’s hospital course was prolonged due to the refractory nature of his pleural effusions, but with targeted antibiotic therapy and respiratory support, he improved and was discharged with outpatient IV antibiotic therapy for total of 6 weeks. 

Discussion: Up to 25% of patients with diverticulitis develop complications. While some complications such as microperforations cause contained pericolic abscesses, macroperforations cause colo-colonic fistulas or widespread abscesses throughout the abdomen, including the liver. If left untreated, it can lead to fulminant sepsis, significantly worsening the patient’s prognosis. In our case, the CT scan was crucial in identifying the hepatopulmonary fistula early, allowing us to drain the abscess promptly. Surgical decortication would have likely been pursued if patient had not improved with time. 


Recurrent Pleural Effusions from Hepatopulmonary Fistula Secondary to Perforated Diverticulitis

Abstract:
Background: Malaria caused by Plasmodium vivax is often considered less severe than infections caused by other Plasmodium species. However, recent evidence suggests that P. vivax can lead to severe complications, including hepatic dysfunction and transudative ascites. This case report describes an unusual presentation of severe P. vivax malaria in a 14-year-old female, characterized by persistent vomiting, loose stools, jaundice, and high-grade fever with rigors.
Case Presentation: The patient, who had a history of acute gastroenteritis, was admitted with symptoms persisting for 8 days. Initial findings included anemia, elevated liver enzymes, and transudative ascites. Diagnostic imaging revealed splenomegaly, an enlarged liver, and mild ascites. Ascitic fluid analysis was consistent with transudative ascites and showed elevated adenosine deaminase (ADA) levels. The diagnosis of P. vivax malaria was confirmed by identifying gametocytes in the peripheral blood smear. Treatment with intravenous Sulbactam and Artemisinin resulted in significant clinical improvement.
Discussion: This case highlights the potential for severe manifestations of P. vivax malaria, including jaundice, hepatic dysfunction, and transudative ascites. The patient's presentation underscores the need for a high index of suspicion for malaria in endemic regions, especially when clinical symptoms overlap with other tropical diseases. The resolution of symptoms with appropriate treatment supports the diagnosis and emphasizes the importance of timely intervention.

Unraveling the connection between Vivax Malaria and Transudative Ascites. A case report and literature review

Abstract Title: Unveiling the Cholestatic Phenotype: A Case of Autoimmune Hepatitis with Severe Hyperbilirubinemia 

Background: Autoimmune hepatitis (AIH) is defined by clinical, laboratory, and histologic findings as a hepatitic syndrome rather than a cholestatic syndrome. Cholestasis in AIH is typically due to associated primary biliary cirrhosis or primary sclerosing cholangitis. However, 8% cases of AIH have unexplained cholestasis (the Cholestatic-phenotype). In this case report, we described a patient who presented with cholestasis but was later diagnosed with AIH, responding well to steroid treatment. 

Case Presentation: A 52-year-old woman presented to the emergency department with a 15-day history of yellowing of the eyes and urine, accompanied by fatigue and pale-stools, following a brief febrile illness. Initial treatment with empirical antibiotics and supportive care at a local health center showed no improvement. Her medical history was unremarkable except for a similar episode of jaundice 4 years prior. Physical examination was normal, but laboratory tests revealed normocytic normochromic anemia, markedly elevated bilirubin (total 27 mg/dl, direct 15 mg/dl, indirect 12 mg/dl), and liver enzymes (AST-239 IU/L, ALT - 93 IU/L). Further evaluation showed a positive antinuclear antibody (ANA) profile with antibodies against SS-A, Scl-70 and Jo-1, but negative for anti-LKM, anti SMA and AMA. Liver ultrasound revealed altered liver echotexture without strictures or other abnormalities. Liver biopsy demonstrated features of auto-immune hepatitis(Figure 1), with interface hepatitis, cholestasis, chronic inflammatory infiltrates and portal fibrosis. Based on the Revised original scoring system for AIH, the patient had a pretreatment score of 15 (Simplifed scoring system score of 8) ,confirming the diagnosis. Treatment with azathioprine and prednisolone was initiated, with subsequent follow-up showing a positive response. Bilirubin levels normalized within two months. 

Discussion: For patients with cholestasis, especially with elevated bilirubin and positive ANA profile, AIH should be one of the differential diagnosis. Even if the classic serological markers like anti LKM and anti-SMA are negative, biopsy is the key to confirm the diagnosis in patients with such atypical presentation. The standard treatment for AIH is immunosuppressive therapy using steroids and steroid sparing agent such as azathioprine. Steroids such as prednisolone reduces the inflammation acutely and azathioprine is used for long-term chronic therapy to maintain the remission without the fear of steroid dependence.

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Effective Management of Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (Pandas) in a 15-year-old girl: A Case Report

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Iatrogenic Acute Chest Syndrome in a Patient with Sickle Cell Disease.

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