Special clinical challenges in autoimmune hepatitis: the elderly, males, pregnancy, mild disease, fulminant onset, and nonwhite patients.

Autoimmune hepatitis has diverse presentations that may mask its identity, affect its clinical behavior, and confound its management. The objectives of this report are to characterize the populations that are underdiagnosed or difficult to manage and to provide guidelines for meeting their challenges. The elderly have an aggressive, indolent liver disease that responds well to conventional corticosteroid treatment, but the diagnosis of this disease can be hampered by concurrent illnesses and medication. Genetic factors affect the expression and outcome of autoimmune hepatitis in different genders, and they may influence the nature and reactivity to triggering antigens or hormonal imbalances. Pregnancy can ameliorate autoimmune hepatitis, whereas delivery can exacerbate it. Asymptomatic patients and those with mild laboratory derangements may not require immediate therapy, but they commonly require treatment later. Centrilobular zone 3 necrosis can characterize an acute, severe, or fulminant presentation, and corticosteroid therapy can be lifesaving if effective within 2 weeks. Region-specific etiological agents, host-dependent susceptibility factors, and socioeconomic conditions may diversify the presentation in different ethnic groups. The special clinical challenges are essential to recognize and treat properly, and they may also extend hypotheses of pathogenesis.