Recovery fulminant hepatitis A in systemic juvenile idiopathic arthritis patient treated with tocilizumab: a case report

INTRODUCTION: Systemic juvenile idiopathic arthritis (sJIA) is a rare systemic immune disorder that affects patients before 16 years of age. Several viruses have been reported to trigger this disease. Increased use of biologics, such as tocilizumab and anakinra, and decreased use of glucocorticoid may lead to improved outcomes in patients with sJIA. Serious liver injuries induced by tocilizumab include acute liver failure, hepatitis, and jaundice. Hepatitis A remains a highly prevalent disease in low-income countries. CASE PRESENTATION: A 14-year-old Syrian child was diagnosed with sJIA and treated with different DMARDs, including MTX. Tocilizumab was then added as monotherapy and stopped after 12 doses after full diseases remission and normal laboratory tests. He presented with a very high alanine transferase, aspartate transferase, a spiked fever, and fatigue. He was infected with hepatitis A. DISCUSSION: Liver abnormalities are uncommon in sJIA. Acute liver failure may develop a few months after the onset of sJIA. Although acute infections with the hepatitis A virus in children are self-limited, 0.1% of patients progress to fulminant hepatic failure, which spontaneously recovers in 40% of cases. No data are available concerning the coexistence of hepatitis A and sJIA. Our case was the first case presenting fulminant Hepatitis A in a sJIA patient treated with tocilizumab, which had recovered, and the authors initiated Anakinra as a treatment. CONCLUSION: Further follow-up and cohort studies are needed to find the exact prevalence and coexistence of Fulminant Hepatitis A in the coarse of sJIA treated with tocilizumab.