Abstract
We report a woman in her 50s who presented with jaundice and severe hepatocellular injury, concurrently found to have newly diagnosed advanced HIV infection (CD4 count 17, viral load 195 600 copies/mL). In this context, infectious hepatitis or opportunistic infections were the important initial consideration, but viral serology, imaging and liver biopsy excluded opportunistic and viral causes. Markedly raised immunoglobulin G, positive anti-nuclear and smooth muscle antibodies, typical histology and rapid response to corticosteroids confirmed acute autoimmune hepatitis (AIH). She improved on prednisolone, transitioned to azathioprine and commenced antiretroviral therapy with subsequent normalisation of liver function and undetectable HIV viral load. De novo AIH presenting concurrently with advanced HIV and profound immunosuppression is exceptionally rare, with few reported cases in the literature. It highlights that, even in this paradoxical setting, diligent investigation can uncover rare but treatable causes of liver dysfunction.