# Differentiating Autoimmune Hepatitis From Sulfasalazine Toxicity: The Value of Clinicopathologic Correlation

## TL;DR

This case study shows how to distinguish liver damage from sulfasalazine from autoimmune hepatitis using clinical and lab findings.

## Contribution

The paper provides a case demonstrating the importance of clinicopathologic correlation in diagnosing drug-induced liver injury in autoimmune patients.

## Key findings

- A patient with Sjögren's disease and SLE developed severe liver injury linked to sulfasalazine.
- Positive ANA did not confirm autoimmune hepatitis; clinical and histological evidence supported drug-induced injury.
- Discontinuation of sulfasalazine led to rapid liver function improvement.

## Abstract

Sulfasalazine is one of the commonly used disease-modifying anti-rheumatic drugs (DMARDs) for many inflammatory and autoimmune illnesses. Sulfasalazine is generally safe with consistent monitoring, as it can rarely cause clinically significant drug‑induced liver injury (DILI). Diagnosing DILI can be challenging in patients with autoimmune diseases due to positive baseline autoantibodies that may mimic autoimmune hepatitis (AIH) or lupus‑associated hepatitis. This case highlights severe hepatocellular DILI temporally associated with sulfasalazine exposure in a patient with Sjögren's disease and systemic lupus erythematosus (SLE), where positive antinuclear antibody (ANA) could have misleadingly suggested an autoimmune liver disease. Clinical course, targeted serologies, imaging, and histology supported sulfasalazine‑induced liver toxicity rather than autoimmune or viral hepatitis. Early recognition and discontinuation of the drug were associated with rapid clinical and biochemical improvement in liver function.