Missing The Overlap

A 43-year-old female presented with painful obstructive jaundice, a mixed pattern of elevation of liver injury markers and neutrophilic leukocytosis. Evaluation with endoscopic retrograde cholangiopancreatography (ERCP) was unremarkable. The antimitochondrial antibody (AMA) titers were elevated. She was discharged on ursodeoxycholic acid (UDCA) for Primary Biliary Cirrhosis (PBC) but was readmitted for worsening symptoms. The patient's liver biopsy results suggested Overlap syndrome (Primary Biliary Cirrhosis-Autoimmune hepatitis). She was then given corticosteroid therapy concurrently with UDCA after which she improved and remained asymptomatic. In conclusion, we would like to report this atypical presentation of overlap syndrome and hope the medical community learns from our experience by considering overlap syndrome when they see patients without the standard clinical picture of Primary Biliary Cirrhosis or Autoimmune Hepatitis.