Rare Lupus Exacerbation Shines Light on Provider Bias in a Patient With Possible Autoimmune Hepatitis

A 42-year-old woman with a past medical history of alcohol use disorder, decompensated alcoholic cirrhosis, systemic lupus erythematosus (SLE), rheumatoid arthritis, and celiac disease presented to the emergency department (ED) for a four-day history of painful rash with worsening pruritus and acute kidney injury. After admission, dermatology, rheumatology, and nephrology teams were consulted, and a skin and renal biopsy were obtained, with results significant for lupus erythematosus tumidus (LET), lupus nephritis grade III (not active), and IgA nephritis, consistent with a systemic lupus erythematosus exacerbation. Despite the patient's history of autoimmune disease, she had previously never received a biopsy for autoimmune hepatitis (AIH) during her initial diagnosis of cirrhosis. During her admission, an autoimmune hepatitis panel was obtained with results suggestive of autoimmune hepatitis; however, a conclusive diagnosis requires a liver biopsy, which was not obtained inpatient. In patients with a strong history of alcohol use, anchoring on substance use as the sole driver of liver disease may be easy, but this case highlights the importance of keeping a wide differential and considering related illnesses, even in patients with pre-existing diagnoses.