Sequential Plasma Exchange and Tacrolimus for Probable Autoimmune Hepatitis Presenting As Acute-on-Chronic Liver Failure

Autoimmune hepatitis (AIH) is an immune-mediated inflammatory liver disease that may first become apparent through severe decompensation of previously unrecognized cirrhosis.We report a 46-year-old woman with probable AIH (simplified diagnostic score 6), culture-negative spontaneous bacterial peritonitis, marked jaundice, and subsequent West Haven grade III hepatic encephalopathy despite corticosteroid therapy.Liver and cerebral failure were consistent with European Association for the Study of the Liver-Chronic Liver Failure grade 2 acute-on-chronic liver failure, conditional on the clinical diagnosis of cirrhosis.Liver transplantation was unavailable locally.Five therapeutic plasma exchange sessions produced an initial improvement in bilirubin and neurological status, but asterixis and hyperbilirubinemia recurred after an approximately nine-day interval.Three further exchanges were followed by tacrolimus at 1 mg twice daily.At the last follow-up, encephalopathy had not recurred, and aminotransferases had improved, although marked cholestasis and mild ascites persisted.Plasma exchange may provide temporary support while further treatment is established, but this observation cannot isolate its effect from concurrent immunosuppression and infection management.