Young Male With Cryptogenic Hepatitis-Associated Aplastic Anemia

Introduction Acute hepatitis is usually caused by viral, toxins, drugs, ischemia and autoimmune causes. In some situations, no clear etiology for hepatitis can be found (cryptogenic).There has been association with cryptogenic hepatitis and aplastic anemia .Aplastic anemia can pose serious morbidity and mortality to patients. Case Description A 19 year old male, originally from Mongolia, immigrated to the United States 2 months prior to the onset of jaundice.His symptoms started 1 month prior when he presumed he had food poisoning from spoiled chicken. When fatigue persisted past 1-2 days, he became concerned that he acquired the influenza virus. He then took acetaminophen (1000-1500 mg per day, for 2 days) and oseltamivir. He presented to urgent care with jaundice.His history was notable for no sick contacts, tobacco use of 2-3 cigarettes per day,1-2 beers/month and no drug use.He denied herbal or cultural supplement use. Family history was negative for liver disease. AST was 1237 IU/L,ALT 3094 IU/L, total bilirubin 20.2 mg/dl and INR of 1.2.His work up for acute hepatitis including viral and autoimmune serologic tests were negative(See Figure).Liver Ultrasound and CT abdomen/pelvis with contrast showed normal appearing liver with patent hepatic vasculature and non dilated common bile duct.Liver biopsy showed mild/moderate hepatitis with absence of plasma cell infiltration .His liver function tests trended down to normal over the next 10 days.However, his white blood cell count, hemoglobin and platelet counts all began to fall on day 5.Due to this new pancytopenia, he underwent Bone marrow biopsy which showed histology consistent with aplastic anemia. He was started on Anti-thymocyte Globulin, cyclophosphamide and steroids.His pancytopenia did not improved after 10 days. He was then referred for bone marrow transplant. Discussion Cryptogenic Hepatitis Associated Aplastic anemia (CHAAA) is an uncommon but distinct variant of aplastic anemia with hepatitis documented in 2-5 % of case of Aplastic Anemia .CHAAA most often affects young males who present with severe pancytopenia within 2-3 months (14-225days )after an episode of acute hepatitis. Most patients test negative for viral hepatitis serologies. The clinical features and response to immunosuppressive therapy suggest underlying immunological mechanisms. Unfortunately not all patients will respond to immunosuppressive therapy.2238_A Figure 1. Autoimmune and viral work up2238_B Figure 2. HB and platelets2238_C Figure 3. BM biopsy

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