title: Recurrent liver failure caused by IgG4 associated cholangitis.
abstract: Immunoglobulin G4 associated cholangitis (IAC) is an autoimmune disease associated with autoimmune pancreatitis (AIP). It presents with clinical and radiographic findings similar to primary sclerosing cholangitis (PSC). IAC commonly has a faster, more progressive onset of symptoms and it is more common to see obstructive jaundice in IAC patients compared to those with PSC. One of the hallmarks of IAC is its responsiveness to steroid therapy. Current recommendations for treatment of AIP demonstrate excellent remission of the disease and associated symptoms with initiation of steroid therapy followed by steroid tapering. If untreated, it can progress to irreversible liver failure. This report describes a 59 year-old female with undiagnosed IAC who previously had undergone a pancreaticoduodenectomy for a suspected pancreatic cancer and later developed liver failure from presumed PSC. The patient underwent an uncomplicated liver transplantation at our institution, but experienced allograft failure within five years due to progressive and irreversible bile duct injury. Radiology and histology suggested recurrence of PSC, but the diagnosis of IAC was suspected based on her past history and confirmed when IgG4 positive cells were found within the intrahepatic bile duct walls on a liver biopsy. A successful liver retransplantation was performed and the patient is currently on triple immunosuppressive therapy. Our experience in this case and review of the current literature regarding IAC management suggest that patients with suspected or recurrent PSC with atypical features including history of pancreatitis should undergo testing for IAC as this entity is highly responsive to steroid therapy.
authors.affiliation: Department of Transplantation, Mayo Clinic Florida, Jacksonville, Florida 32224, USA.
authors.forename: Jacob N
authors.initials: JN
authors.lastname: Clendenon
authors.forename: Jaime
authors.initials: J
authors.lastname: Aranda-Michel
authors.forename: Murli
authors.initials: M
authors.lastname: Krishna
authors.forename: C Burcin
authors.initials: CB
authors.lastname: Taner
authors.forename: Darrin L
authors.initials: DL
authors.lastname: Willingham
mesh_terms: D001327:Autoimmune Diseases / Q000175:diagnosis / Q000188:drug therapy / Q000276:immunology*; D015209:Cholangitis, Sclerosing / Q000175:diagnosis / Q000188:drug therapy / Q000276:immunology*; D004359:Drug Therapy, Combination; D005260:Female; D006801:Humans; D007074:Immunoglobulin G / Q000097:blood*; D007166:Immunosuppressive Agents / Q000627:therapeutic use; D017093:Liver Failure / Q000276:immunology* / Q000601:surgery; D016031:Liver Transplantation; D008875:Middle Aged; D016577:Pancreaticoduodenectomy; D050500:Pancreatitis, Chronic / Q000175:diagnosis / Q000188:drug therapy / Q000276:immunology* / Q000601:surgery; D012008:Recurrence; D012086:Reoperation; D013256:Steroids / Q000627:therapeutic use; D017211:Treatment Failure
chemical_list: D007074:Immunoglobulin G; D007166:Immunosuppressive Agents; D013256:Steroids