A 49 year old female was diagnosed with primary biliary cirrhosis (PBC) and stage III fibrosis on liver biopsy 2 years ago; granulomas and peribiliary inflammation were prominent. She was started on ursodiol and followed longitudinally.
Recently, it was noted that transaminase levels had not normalized despite the ursodiol treatment, and furthermore, the patient had an elevated IgG. She was rebiopsied to determine if she had a component of autoimmune hepatitis (an overlap syndrome, PBC + AIH), which could explain the treatment non-response.
Sure enough, her most recent biopsy (shown above) has the classic features of AIH: a rich plasma cell infiltrate and interface hepatitis, also called piecemeal necrosis. On this image, you can see the interface hepatitis extending from the portal triad into the hepatic lobule at 9 o’clock. The plasma cells are noted by their oval appearance with prominent, purple nuclei and pink cytoplasm.