Severe autoimmune hepatitis in patients with previous spontaneous recovery of a flare

Background/Aims: Autoimmune hepatitis can present acutely and pursues a variable, usually progressive course. Spontaneous remissions have been described, but their influence on the course of subsequent attacks has not yet been studied. Methods: Charts from 1980 to 2000 were reviewed. Cases of autoimmune hepatitis were further examined to identify those with prior episodes of transient elevation of the serum aminotransferase activities of unknown etiology. Results: Fifty-one patients with autoimmune hepatitis were identified, nine of whom (18%) had experienced a transient episode of elevated aminotransferase activities which had resolved spontaneously. The median period of time separating the two flares was 10 months (range: 4 months–23 years). The median age at diagnosis was 41 years in both groups. More than 75% of the patients in either group suffered from a type 1 autoimmune hepatitis. Importantly, patients with spontaneous recovery of a previous episode had a higher serum alanine transaminase activity (P<0.02), were less likely to respond to immunosuppressive therapy (78 versus 98%, P=0.077) and required transplantation more frequently (22 versus 0%, P=0.028). Histologically, these patients did not have more fibrosis than patients without previous flare. Conclusions: More than 10% of autoimmune hepatitis may begin with a spontaneously resolving episode. However, the spontaneous recovery of a previous attack should not falsely reassure: a subsequent flare of autoimmune hepatitis can still be severe.