To the editor:

We read with great interest the case study report of Rodrigues et al. [1] regarding concurrent systemic sclerosis (SSc) and autoimmune hepatitis (AIH). The coexistence of AIH and some connective tissue diseases such as rheumatoid arthritis, Sjogren’s syndrome, and systemic lupus erythematosus is well known; but the coexistence of SSc and AIH is very rare. To date, only a few cases have been reported.

The authors described an SSc patient who diagnosed with positive antimitochondrial antibody (AMA) concomitant with AIH. They reported about 17% of AIH patients may be positive for AMA. However, it is important to note that AMA positivity can also be seen in nearly one quarter of patients with SSc [2].

Recently, we reported an AIH patient with SSc treated with prednisolone 50 mg/day, azathioprin 50 mg/day, and low-dose angiotensin converting enzyme inhibitor. This approach showed us that such patients can be treated with high-dose steroid. After immunosuppressive therapy, biochemical remission was achieved in our patient; but in follow-up, portal hypertension and esophageal varices were developed. After careful evaluation of the patient reported by Rodrigues et al., we noticed that the patient’s INR value increased from 1.06 to 1.24. For that reason, we concluded that the patient was in hepatic failure despite of biochemical remission [1, 2].

In conclusion, large population-based studies may not be feasible due to rarity of the condition. However, we might conclude an acceptable approach from such individual cases. It should be kept in mind that biochemical response may not reflect complete remission in patient with AIH.