Atypical Presentation of Autoimmune Hepatitis: Diagnostic Challenges and the Role of Immunosuppressive Therapy in Clinical Stabilization

Background: Autoimmune hepatitis (AIH) is a chronic, immune-mediated liver disease that can present with a spectrum of clinical symptoms ranging from asymptomatic transaminitis to acute liver failure. Serological markers, elevated liver enzymes, and liver histopathology often guide the diagnosis. However, in some cases, incomplete or nonspecific serological profiles complicate early diagnosis. Case Summary: We report a case of a 45-year-old female who initially presented in 2023 with jaundice, fatigue, and significantly elevated liver enzymes. A weakly positive ANA and negative viral and other autoimmune markers were noted, but liver biopsy was deferred. After two years of being lost to follow-up, she re-presented in 2025 with recurrent symptoms and further deterioration in liver function. Imaging showed early signs of chronic liver disease. A liver biopsy revealed stage F2 fibrosis and classic histopathological features of AIH, confirming the diagnosis. Immunosuppressive therapy with prednisolone and azathioprine was initiated, resulting in clinical stabilization and biochemical improvement. Discussion and Conclusion: This case underscores the importance of maintaining clinical vigilance and pursuing liver biopsy in uncertain cases, even with inconclusive serology. Early diagnosis and treatment are critical to preventing irreversible liver damage in AIH