Re: Antimitochondrial Antibodies

[HFHS-MD-dm]

Posted By HFHSM.D.-DM on August 21, 1998 at 18:44:04:

In Reply to: Antimitochondrial Antibodies posted by Steve on August 20, 1998 at 01:47:45:






My wife is 41 and has the following blood work:
Antimitochondrial Antibodies: Positive Titer of 1:160
GGT: Decreasing from 272 u/L in May 1998 to 148 u/L now
AST: Decreasing from 70 u/L in May 1998 to 40 u/L now
ALT: Decreasing from 96 u/L in May 1998 to 47 now
Albumin: 3.7-4.0
Bilirubin: 0.8-1.0
Alkaline Phosphatase: 75-104
LKM Antibodies: Negative <1:10 Titer
ANA Antibodies: Negative
Thyroid Peroxidase Antibodies: 16 u/mL
Thyroglobulin Antibodies: 1.8 u/mL
Alpha-1 Antitrypsin: 192 mg/dL
Hepatitis Panel (chronic): Non-Reactive
Serum Copper: 78 mcg/dL
She has been on Synthroid for hypothyroidism for about 10 years.
In May 1998 she also developed chronic hives, which appear to be decreasing in severity as the GGT, AST and ALT improve.
Do the positive Antimitochondrial Antibodies at such a high titer necessarily indicate Primary Biliary Cirrhosis?
Is it possible to get Antimitochondrial Antibody profile testing to discriminate between a benign or progressive course of PBC as we read about in Liver, Vol 17, Issue 3?
We suspect the possibility of an immune-mediated drug-induced hepatitis, based on exposure to some chemicals.
Please ask if you want to know the drugs we suspect.
Have you heard of any drug-induced cases involving Antimitochondrial Antiboddies?
Should we look for a hepatologist specializing in PBC, autoimmune hepatitis, or drug-induced hepatitis; or is a regular gastroenterologist good enough?
How do you find a good hepatologist besides looking at Ford?
Thank you for the service and your efforts.



_


Dear Steve:
You ask a lot of good questions about your wifes situation and perhaps we can work through them one by one.  I just want to make sure I understand her situation.  She developed hives and liver enzyme abnormalities several months ago and both are improving.  In fact, if I assume your laboratory uses the same normal liver enzyme values as ours, your wifes numbers are approaching normal.  The rest of her evaluation is normal except for an elevated AMA at 1:160.  Now lets go through your questions.

Do the positive Antimitochondrial Antibodies at such a high titer necessarily indicate Primary Biliary Cirrhosis?
Your wife does have high titers and this is suspicious for Primary Biliary Cirrhosis (PBC), however, it is possible to have an elevated AMA and not have PBC.  In fact, about 10% of the healthy relatives of patients with PBC have elevated AMA titers.  I periodically see patients who are sent to me with elevated AMA titers but who do not have evidence of PBC on liver biopsy.  I cannot, exclude, however, that these patients have an extremely early form of PBC.  Perhaps, it might be interesting to see if your wife still has an elevated AMA when her hives resolve completely.  
Is it possible to get Antimitochondrial Antibody profile testing to discriminate between a benign or progressive course of PBC as we read about in Liver, Vol 17, Issue 3?
Several studies over the years have suggested that both the actual titer or pattern of anti-mitochondrial antibodies can correlate with disease progression.  However, we do not use this information to gauge how individual patients are doing because we feel other parameters such as the liver biopsy, clinical assessment and liver enzyme tests give us an excellent and better feel for how a patient is doing.  We have a lot of information generated over the years using these criteria.  I note, however, that at this time we do not know if your wife even has PBC and I would make that diagnosis on the basis of the elevated AMA alone.  
We suspect the possibility of an immune-mediated drug-induced hepatitis, based on exposure to some chemicals.
Please ask if you want to know the drugs we suspect.
Have you heard of any drug-induced cases involving Antimitochondrial Antiboddies?
Many drugs can cause a form of immune-mediated hepatitis.  I do not know of any specific drugs that give elevated AMA titers but it is certainly possible that some do. Again, it might be interesting to see if your wife still has an elevated AMA when her hives resolve completely.
Should we look for a hepatologist specializing in PBC, autoimmune hepatitis, or drug-induced hepatitis; or is a regular gastroenterologist good enough?
How do you find a good hepatologist besides looking at Ford?
I think you should see a hepatologist.  Because it is not clear what your wifes diagnosis, I would not recommend seeing a hepatologist with a specific specialization.  Hepatology is pretty specialized as it is.  What I often suggest to readers of MEDHELP is that they get the name of a good hepatologist at a reputable university medical center in their area.  Almost every state has one.  While, I would never suggest a university or medical school physician is better than one in the community, physicians at university medical centers are often sent complex and difficult cases and develop some expertise in evaluating and caring for these patients.  If you would like to tell me where you are located, I might be able to help you locate such a individual.  
I hope this information is helpful to you. Good luck with your problem.  If you have additional questions or more information, feel free to post the material back to MEDHELP or you are always welcome to contact us directly at Henry Ford at [phone].  If you are in the Detroit area, we would always welcome to come see us.  We have a very active group of liver specialists.  
This response is being provided for general informational purposes only and should not be considered medical advice or consultation.  Always check with your personal physician when you have a question pertaining to your health.