a 32-year - old overweight non - alcoholic non - smoker bengali man was admitted to our hospital with jaundice , nausea , non - bilious , non - bloody vomiting , and worsening malaise for 3 days .
his past medical history was significant for type 2 diabetes mellitus , hypertension , and hyperlipidemia .
he denied any sick contacts , use of herbs , or recent change in medications .
his physical examination was significant for normal vital signs , scleral icterus , and without stigmata for chronic liver disease .
laboratory values on admission and during the hospital course are shown in table 1 . in our patient ,
initial workup revealed alkaline phosphatase ( alp)/aspartate transaminase ( ast ) with ratio < 1.5 , more than twofold increase in igg , antinuclear antibody ( ana ) , and anti - smooth muscle antibody ( asma ) titer > 1:80 , anti - mitochondrial antibody ( ama ) positive , negative drug history , and no alcohol intake . a liver biopsy performed showed lymphoplasmacytic portal inflammation with significant interface hepatitis and cholestasis ( figs . 1 and 2 ) .
these clinical findings added up to an international autoimmune hepatitis group ( iaihg ) score of 13 points .
because the patient emigrated from an endemic area for hepatitis e about 1 month prior to presentation , hev igm was checked , which subsequently returned positive .
the test was performed by focus diagnostics , inc . based out of san juan capistrano , ca , using enzyme linked immunosorbent assay method .
he improved clinically with significant improvement of his liver function tests over the next month .
portal inflammation ( vertical arrow ) with interphase hepatitis and cholestasis ( horizontal arrow ) .
iaihg developed a diagnostic scoring system , which outlined 13 criteria for the diagnosis of aih in a majority of the patients .
it included gender ; alp to ast or alanine transaminase ( alt ) ratio ; serum globulins or igg levels ; ana , asma , or anti - liver - kidney microsome antibodies ; ama ; hepatitis viral markers ; drug history ; average alcohol intake ; liver histology ; other autoimmune diseases ; seropositivity for other defined autoantibodies ; hla dr3 or dr4 ; and response to therapy ( 6 ) . in our case
, the iaihg score of 13 points meets the criteria for  probable aih. concomitantly , he was positive for anti - hev igm and igg antibodies suggesting acute hev infection .
the pathophysiology of these concomitant presentations of aih and hev seroprevalence is not well understood .
several studies have reported the presence of anti - hev igg antibodies in patients with aih suggesting that hev infection may act as a possible trigger or hapten for the development of aih ( 5 ) .
similar to our case , ama is found to be present in sera of patients with aih more frequently than expected .
resolution of abnormal liver function test and clinical recovery in a short period of 68 weeks without any intervention is unlikely in patient with aih ( 8) .
hev pcr is considered to be the most sensitive test for diagnosing acute hev infection . however , a recent investigation showed a variable sensitivity for different hev pcr assays ( 9 ) .
similar cases with a concomitant presentation of hev and autoimmune mimicry have been reported in the literature ( 10 , 11 ) .
this case illustrates the importance of excluding acute hev in patients with criteria for  probable aih from an endemic area .
effect of steroids in such cases , beneficial or harmful , is unclear given the paucity of data in the literature . in conclusion ,
our case is unique as it shows that in - patients who are clinically stable and improving with conservative management , treatment with steroids should be delayed until hev is appropriately ruled out .
the authors declare that there is no conflict of interest regarding the publication of this article .
 a 32-year - old immigrant man presented with new onset jaundice . 
 his past medical history was significant for type 2 diabetes mellitus , hypertension , and hyperlipidemia . 
 his initial laboratory finding and liver biopsy were suggestive of autoimmune hepatitis ( aih ) . 
 the plan was to start steroids pending negative results for viral serology , but it came back positive for hepatitis e virus . 
 the patient 's liver function test and clinical condition improved significantly on conservative management over a period of 1 month . 
 therefore , we suggest testing for hepatitis e especially in immigrants or recent travelers to endemic areas who presents with clinical features suggestive of aih . 
Case presentation
Discussion
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