Etanercept-induced granulomatous hepatitis as a rare cause of abnormal liver tests

The authors report the case of a 76 year-old man with rheumatoid arthritis treated with prednisolone and etanercept. The patient was seen for persistent changes in liver tests lasting for six months, with a mixed pattern. The patient denied intake of new drugs or dietary/herbal supplements. Imaging studies showed mild steatosis. Additional study for chronic liver diseases only revealed positivity for anti-nuclear antibodies. Liver biopsy revealed noncaseating granulomas in some portal tracts. Consequent etiologic study for granulomatous diseases showed negative or normal results. So it was decided to suspend etanercept, with a subsequent gradual improvement on analytical parameters that normalized three months later. To date, only one case of granulomatous liver disease associated with an anti-TNF agent was described in the literature. This case also raises the question whether the development of granulomatous processes associated with anti-TNF agents has been underdiagnosed due to the presence of other concomitant immunosuppressant therapies. (Acta gastroenterol. belg., 2019, 82, 93-95).