Autoimmune hepatitis — MCQs

A 75-year-old woman comes to the physician because of a 6-month history of fatigue. During this period, she has had fever, pain in both shoulders and her hips, and a 5-kg (11-lb) weight loss. She also reports feeling stiff for about an hour after waking up. She has a history of hypertension and hypercholesterolemia. There is no family history of serious illness. She has smoked a pack of cigarettes daily for the past 50 years. Her medications include hydrochlorothiazide and atorvastatin. She appears pale. Her temperature is 38°C (100.4°F), pulse is 90/min, and blood pressure is 135/85 mm Hg. Range of motion of the shoulders and hips is reduced due to pain. Examination shows full muscle strength. The remainder of the examination shows no abnormalities. Laboratory studies show an erythrocyte sedimentation rate of 50 mm/h and a C-reactive protein concentration of 25 mg/dL (N=0–10 mg/dL). Which of the following is the most appropriate next step in management?

A 35-year-old woman comes to the physician because of a 3-month history of progressive fatigue, shortness of breath, and pain in her knees and ankles. Her temperature is 37.6°C (99.7°F). Physical examination shows mild hepatomegaly and tender, red nodules on her shins. There are purple, indurated lesions on her nose, nasolabial fold, and cheeks. A biopsy of the liver shows scattered aggregations of multinucleated giant cells with cytoplasmic inclusions and eosinophilic, needle-shaped structures arranged in a star-like pattern. Which of the following is the most likely cause of this patient's symptoms?

A 59-year-old woman comes to the physician for a routine health maintenance examination. She feels well. She has systemic lupus erythematosus and hypertension. She does not drink alcohol. Her current medications include lisinopril and hydroxychloroquine. She appears malnourished. Her vital signs are within normal limits. Examination shows a soft, nontender abdomen. There is no ascites or hepatosplenomegaly. Serum studies show: Total bilirubin 1.2 mg/dL Alkaline phosphatase 60 U/L Alanine aminotransferase 456 U/L Aspartate aminotransferase 145 U/L Hepatitis A IgM antibody negative Hepatitis A IgG antibody positive Hepatitis B surface antigen positive Hepatitis B surface antibody negative Hepatitis B envelope antigen positive Hepatitis B envelope antibody negative Hepatitis B core antigen IgM antibody negative Hepatitis B core antigen IgG antibody positive Hepatitis C antibody negative Which of the following is the most appropriate treatment for this patient?

A 62-year-old woman with a history of hypertension, hyperlipidemia, and rheumatoid arthritis presents for evaluation of elevated serum liver chemistries. She has had three months of intense, unremitting itching. Current medications include chlorthalidone, atorvastatin, and ibuprofen. Physical exam is unremarkable. Laboratory studies show aspartate aminotransferase (AST) 42 units/L, alanine aminotransferase (ALT) 39 units/L, alkaline phosphatase 790 units/L, total bilirubin 0.8 mg/dL, and antimitochondrial antibody titer 1:80. What do you expect to see on liver biopsy?

A 45-year-old man comes to the physician for a routine health maintenance examination. He feels well. He has type 2 diabetes mellitus. There is no family history of serious illness. He works as an engineer at a local company. He does not smoke. He drinks one glass of red wine every other day. He does not use illicit drugs. His only medication is metformin. He is 180 cm (5 ft 11 in) tall and weighs 100 kg (220 lb); BMI is 31 kg/m2. His vital signs are within normal limits. Examination shows a soft, nontender abdomen. The liver is palpated 2 to 3 cm below the right costal margin. Laboratory studies show an aspartate aminotransferase concentration of 100 U/L and an alanine aminotransferase concentration of 130 U/L. Liver biopsy shows hepatocyte ballooning degeneration, as well as inflammatory infiltrates with scattered lymphocytes, neutrophils, and Kupffer cells. Which of the following is the most likely diagnosis?

A 42-year-old woman presents complaining of pain in her hands. She reports that the pain is in both hands, and that it is usually worse in the morning. She reports that her hands are also stiff in the morning, but that this gradually improves throughout the morning. She notes, however, that her symptoms seem to be getting worse over the last three months. What is the most likely pathogenesis of her disease process?

A 44-year-old woman presents to the emergency department with jaundice and diffuse abdominal pain. She denies any previous medical problems and says she does not take any medications, drugs, or supplements. Her temperature is 97.6°F (36.4°C), blood pressure is 133/87 mmHg, pulse is 86/min, respirations are 22/min, and oxygen saturation is 100% on room air. Physical exam is notable for sclera which are icteric and there is tenderness to palpation over the right upper quadrant. Laboratory studies are ordered as seen below. Hepatitis B surface antigen: Positive Hepatitis B surface antibody: Negative Hepatitis B core antibody IgM: Negative Hepatitis B core antibody IgG: Positive Hepatitis B E antigen: Positive Hepatitis B E antibody (anti-HBe): Negative Which of the following is the most likely diagnosis?

A 36-year-old woman presents for a pre-employment health assessment. She has no complaints. Her last annual physical examination 8 months ago was normal. She has no significant past medical history. She is a nonsmoker and says she quit all alcohol consumption last year. A complete hepatic biochemistry panel is performed, which is significant for a serum alkaline phosphatase (ALP) level 5 times the upper limit of the normal range. Immunologic tests are positive for antimitochondrial antibodies. A liver biopsy is performed and reveals an inflammatory infiltrate surrounding the biliary ducts. Which of the following is the most likely diagnosis in this patient?

A 32-year-old woman comes to the physician with increasing jaundice and fatigue for the past week. She has no history of a serious illness. She takes no medications and denies use of recreational drugs. She does not drink alcohol. Her vital signs are within normal limits. Her body mass index is 21 kg/m2. On physical examination, she has icteric sclera. Otherwise, her heart and lung sounds are within normal limits. Hemoglobin 15 g/dL Leukocyte count 6,000/mm3 with a normal differential Serum bilirubin Total 6.5 mg/dL Direct 0.9 mg/dL Alkaline phosphatase 70 U/L Aspartate aminotransferase (AST, GOT) 430 U/L Alanine aminotransferase (ALT, GPT) 560 U/L γ-Glutamyltransferase (GGT) 43 U/L (N=5-50 U/L) Hepatitis A antibody Negative Hepatitis B surface antigen Negative Hepatitis C antibody Negative Rheumatoid factor 80 IU/mL (N=0-20 IU/mL) Antinuclear antibody (ANA) titer is 1:1280. Polyclonal immunoglobulin gamma is 5 g/dL. Which of the following antibodies is most likely to be positive in this patient?

A 47-year-old Caucasian woman presents with a 2-month history of general fatigue, slight jaundice, and mild itching. She has also noticed that her urine has been darker and stools have been lighter in color recently. She denies any fevers, chills, or alcohol use. She has no significant past medical or surgical history and is not taking any medications. She recalls that her mother saw a doctor for eye and mouth dryness but cannot remember the name of her diagnosis. She denies any illicit drug use, recent change in diet, or recent travel. On physical exam, her abdomen is soft and non-distended. There is right upper quadrant tenderness to deep palpation but a negative Murphy’s sign. Her laboratory findings were significant for increased liver enzymes, direct bilirubin, and alkaline phosphatase with normal levels of iron and ceruloplasmin. Ultrasound revealed no stones in the gallbladder or common bile duct and endoscopic retrograde cholangiopancreatography (ERCP) revealed normal extrahepatic biliary ducts. Which of the following findings is most likely to also be found in this patient?