Antinuclear antibodies positive acute nonfulminant hepatitis A associated with acute renal failure and hives: a case report

Acute hepatitis A (AHA) is a self-limited illness. While the prognosis for hepatitis A is generally good, complications with acute renal failure can have a negative impact. PRESENTATION OF CASE: A 60-year-old male was admitted due to fever and malaise for a week, accompanied by jaundice and reduced urine output over the past 3 days. The patient was exhausted with icteric skin and sclera, dark urine, bilateral pretibial grade II pitting edema, and a urinary output of nearly 1 l/day. Laboratory findings on admission showed acute liver injury and acute kidney injury with positive hepatitis A virus immunoglobulin M. Liver and kidney function tests were augmented gradually aligned with oliguria. Thereafter, the patient had an itchy rash on his back and abdomen. Screening for immune diseases came back negative except for positive antinuclear antibodies. The authors continued conservative management with dialysis, diuretics, and restricted hydration. After five hemodialysis sessions, urinary output improved and liver function tests were improved, however, kidney function tests were slowly improved. One month later, serum creatinine was reduced to 1.4 mg/dl, and 2 months later, it was 1.1 mg/dl. CONCLUSION: The authors experienced a rare case of nonfulminant AHA that resulted in severe acute renal failure and needed dialysis. Several hypotheses had been postulated for AHA-related nephropathy; however, hyperbilirubinemia-induced acute tubular necrosis was the most acceptable theory in the patient. Since AHA associated with antinuclear antibodies positive and hives rash could confuse the diagnosis, clinicians should consider extrahepatic manifestations associated with hepatitis A virus infection in such conditions after excluding immune disorders.