Autoimmune cholangiopathy: the result of consecutive primary biliary cirrhosis and autoimmune hepatitis?

Autoimmune cholangiopathy is a recently proposed entity that describes a specific group of patients presenting overlapping features of primary biliary cirrhosis and autoimmune hepatitis, i.e., clinical and/or biochemical cholestasis, high titer antinuclear antibody, negative antimitochondrial antibody, and elevated immunoglobulin G. Liver histology shows primary biliary cirrhosis coexisting with varying degrees of parenchymal inflammation. In addition, these patients achieve remission on corticosteroid therapy. The patient in this report fulfilled the above criteria. However, preceding the autoimmune cholangitis stage, a typical antimitochondrial antibody-positive primary biliary cirrhosis was documented with favorable response to ursodeoxycholic acid treatment. Twenty months later, the patient developed autoimmune hepatitis with elevated aspartate aminotransferase and immunoglobulin G and high titer antinuclear antibody as well as corticosteroid dependency, whereas the antimitochondrial antibody disappeared. The patient's sera initially showed reactivity to three mitochondrial proteins, the 74-, 64-, and 56-kilodalton autoantigens of the 2-oxo acid dehydrogenase complexes, which was characteristic of primary biliary cirrhosis. After developing autoimmune hepatitis, reactivity to the 74- and 64-kilodalton antigens disappeared, whereas reactivity to the 56-kilodalton antigen decreased to low levels. Autoimmune cholangitis and probably other forms of the overlap syndrome may result from the association of two diseases: primary biliary cirrhosis and autoimmune hepatitis.