Scientific Letter
Seronegative autoimmune hepatitis: Description of two paediatric cases
Hepatitis autoinmune seronegativa, descripción de 2 casos en edad pediátrica
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It is diagnosed based on laboratory findings (elevated aminotransferase levels, hypergammaglobulinaemia and presence of antibodies) and compatible findings of liver biopsy: interface hepatitis, plasma cell infiltrate, rosette formation (microacinar transformation of hepatocytes) and/or fibrosis, necrosis and cirrhosis.</p><p id="par0010" class="elsevierStylePara elsevierViewall">In recent years, a new form of disease has been described, seronegative AIH, on which few data have been published in the paediatric literature.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1,2</span></a> It is similar to classic AIH, but is characterised by the absence of antibodies and may present in association with other autoimmune diseases.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">2,3</span></a> It manifests with clinical and biochemical signs of chronic hepatitis in the absence of features indicative of other aetiologies (infectious, metabolic, toxic, etc.). Blood tests usually reveal elevated transaminase levels and absence of antibodies, with additional absence of hypergammaglobulinaemia in up to 25% of cases. Liver biopsy reveals features compatible with AIH, and affected patients respond well to immunosuppressive therapy, as do patients with classic AIH.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">4,5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Considering this newly described form, we reviewed 2 cases of chronic hepatitis of unknown aetiology manifesting with fibrosis on liver biopsy managed in our paediatric gastroenterology clinic, with the purpose of determining whether they may fit the criteria for seronegative AIH.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The first case corresponded to a male patient aged 12 years referred to our clinic for investigation of persistent elevation of serum transaminases of 2 years’ duration (serum glutamic oxaloacetic transaminase [SGOT], 62–325<span class="elsevierStyleHsp" style=""></span>IU/L; serum glutamic pyruvic transaminase [SGPT] 100–430<span class="elsevierStyleHsp" style=""></span>IU/L) detected by chance during a routine blood test. The second corresponded to a female patient aged 6 years that had received a diagnosis of coeliac disease 3 years earlier; she had elevated serum transaminases before diagnosis that persisted in the follow-up blood tests (SGOT, 80–630<span class="elsevierStyleHsp" style=""></span>IU/L; SGPT, 90–820<span class="elsevierStyleHsp" style=""></span>IU/L) despite normalisation of serological markers of coeliac disease.</p><p id="par0025" class="elsevierStylePara elsevierViewall">In both cases, the investigation of the elevation of serum transaminases failed to identify its aetiology: the chemistry and metabolic panels revealed normal iron metabolism, with negative serological markers of coeliac disease (in the second case, initially positive with normalisation after removal of gluten from the diet), absence of clotting abnormalities, normal thyroid function and normal immunoglobulin levels. The patients had no history of exposure to hepatotoxic drugs, and the investigation ruled out infection, classic AIH (due to negative antibody tests), alpha-1 antitrypsin deficiency, Wilson disease, lysosomal acid lipase deficiency and muscle and metabolic disorders. Both patients underwent repeated ultrasound examinations and a magnetic resonance cholangiography, the findings of which were normal. Given that all tests gave negative results while serum transaminases remained elevated, a liver biopsy sample was obtained for histopathological examination, resulting in a diagnosis of idiopathic liver fibrosis in both cases.</p><p id="par0030" class="elsevierStylePara elsevierViewall">We contacted the anatomical pathology department and suggested the possibility of seronegative AIH, which led to performance of a targeted review of the histological features of both cases. The examination revealed cirrhosis and plasma cell infiltration, interface hepatitis in the first case, and necrosis in the second case. Rosettes were not found in either case. Based on these findings, the pathology report indicated that the cases were compatible with seronegative AIH. <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> summarises the anatomical pathology findings and the clinical characteristics of these 2 patients.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">In light of the histopathological findings, and since other aetiologies had been ruled out previously, we proposed the diagnosis of seronegative AIH and, in agreement with the family, decided to initiate treatment in both patients with glucocorticoids at a dose of 2<span class="elsevierStyleHsp" style=""></span>mg/kg/day to be tapered to a maintenance dose of 2.5<span class="elsevierStyleHsp" style=""></span>mg every other day, with introduction of azathioprine on day 15 at a dose of 0.5<span class="elsevierStyleHsp" style=""></span>mg/kg/day, increasing the dose gradually until reaching 2<span class="elsevierStyleHsp" style=""></span>mg/kg/day.</p><p id="par0040" class="elsevierStylePara elsevierViewall">In both patients, the serum transaminase levels (SGOT and SGPT) had normalised at 3 months of treatment, and they remained within the normal range at 6 months with the patients receiving minimum doses of glucocorticoids. <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the evolution of serum transaminase levels in the 2 patients.</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conclusions</span><p id="par0045" class="elsevierStylePara elsevierViewall">In our experience, histological examination by a pathologist with a focus on seronegative AIH in two cases of unspecified fibrosis led to a new diagnosis and allowed effective treatment in both patients.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Seronegative AIH is a newly defined disease for which little data is available in the paediatric age group. At the moment, the possibility of an autoimmune aetiology should be considered in idiopathic cases of chronic hepatitis, especially in patients with a history of other autoimmune diseases such as coeliac disease,<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">2,3</span></a> even if antibody detection tests are negative. We recommend performance of a liver biopsy in such cases and, should the results be compatible with autoimmune disease, early initiation of immunosuppressive therapy to halt the progression of liver disease.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conclusions" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Lahílla Cuello L, Ros Arnal I, García Romero R, Hörndler Argarate C. Hepatitis autoinmune seronegativa, descripción de 2 casos en edad pediátrica. An Pediatr (Barc). 2018;88:285–286.</p>" ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Case 1 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Case 2 \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Age</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 years \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Sex</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Female \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Personal history</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Coeliac disease \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Clinical features</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Asymptomatic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Asymptomatic \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Autoantibodies</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Negative \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Negative \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Antinuclear Ab \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Antimitochondrial Ab \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Anti-smooth muscle Ab \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Anti-parietal cell Ab \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Anti-DNA Ab \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Anti-liver-kidney microsomal antibody type 1 (ALKM-1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Anti-liver cytosol antibody-1 (ALC-1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Ac. anti AMA-M2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Anti F-actin Ab \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Anti-soluble liver antigen/liver pancreas \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Ab (anti-SLA/LP) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Anti-gp210 Ab \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Anti-sp100 Ab \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">IgG</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Within normal range \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Within normal range \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Anatomical pathology</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Interface hepatitis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Plasma cell infiltrate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Rosette formation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Fibrosis, cirrhosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Necrosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1735052.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Clinical characteristics and histological features found in our 2 patients.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Prior to liver biopsy \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">At treatment initiation \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">At 3 months of treatment \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">At 6 months of treatment \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Case 1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">SGOT (IU/L) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">62–325 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">89 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">31 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">40 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">SGPT (IU/L) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100–430 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">163 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">58 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">35 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Case 2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">SGOT (IU/L) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">80–630 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">82 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">26 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">33 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">SGPT (IU/L) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">90–820 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">93 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">22 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">18 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1735051.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Evolution of serum transaminase levels in our 2 patients.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Seronegative autoimmune hepatitis in children: spectrum of disorders" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "G. Maggiore" 1 => "G. Socie" 2 => "M. Sciveres" 3 => "A.M. Roque-Afonso" 4 => "S. Nastasio" 5 => "C. Johanet" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.dld.2016.03.015" "Revista" => array:6 [ "tituloSerie" => "Dig Liver Dis" "fecha" => "2016" "volumen" => "48" "paginaInicial" => "785" "paginaFinal" => "791" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27079745" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0035" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Seronegative autoimmune hepatitis presenting after diagnosis of coeliac disease: a case report" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "M.A. Quail" 1 => "R.K. Russell" 2 => "C. Bellamy" 3 => "G. Mieli-Vergani" 4 => "P.M. 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Czaja" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s10620-011-2017-z" "Revista" => array:6 [ "tituloSerie" => "Dig Dis Sci" "fecha" => "2012" "volumen" => "57" "paginaInicial" => "610" "paginaFinal" => "624" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22187100" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Juvenile autoimmune hepatitis: spectrum of the disease" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "G. Maggiore" 1 => "S. Nastasio" 2 => "M. Sciveres" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.4254/wjh.v6.i7.464" "Revista" => array:6 [ "tituloSerie" => "World J Hepatol" "fecha" => "2014" "volumen" => "6" "paginaInicial" => "464" "paginaFinal" => "476" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25067998" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23412879/0000008800000005/v1_201805020427/S2341287918300541/v1_201805020427/en/main.assets" "Apartado" => array:4 [ "identificador" => "38181" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Scientific letters" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23412879/0000008800000005/v1_201805020427/S2341287918300541/v1_201805020427/en/main.pdf?idApp=UINPBA00005H&text.app=https://analesdepediatria.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341287918300541?idApp=UINPBA00005H" ]
| Year/Month | Html | Total | |
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| 2024 March | 105 | 30 | 135 |
| 2024 February | 149 | 34 | 183 |
| 2024 January | 146 | 27 | 173 |
| 2023 December | 81 | 28 | 109 |
| 2023 November | 97 | 32 | 129 |
| 2023 October | 117 | 66 | 183 |
| 2023 September | 103 | 30 | 133 |
| 2023 August | 78 | 28 | 106 |
| 2023 July | 84 | 21 | 105 |
| 2023 June | 59 | 32 | 91 |
| 2023 May | 82 | 26 | 108 |
| 2023 April | 47 | 19 | 66 |
| 2023 March | 80 | 34 | 114 |
| 2023 February | 71 | 23 | 94 |
| 2023 January | 70 | 29 | 99 |
| 2022 December | 96 | 38 | 134 |
| 2022 November | 102 | 33 | 135 |
| 2022 October | 96 | 56 | 152 |
| 2022 September | 79 | 36 | 115 |
| 2022 August | 79 | 51 | 130 |
| 2022 July | 93 | 35 | 128 |
| 2022 June | 98 | 33 | 131 |
| 2022 May | 105 | 35 | 140 |
| 2022 April | 112 | 39 | 151 |
| 2022 March | 112 | 66 | 178 |
| 2022 February | 128 | 34 | 162 |
| 2022 January | 94 | 29 | 123 |
| 2021 December | 78 | 49 | 127 |
| 2021 November | 84 | 53 | 137 |
| 2021 October | 126 | 83 | 209 |
| 2021 September | 91 | 43 | 134 |
| 2021 August | 81 | 50 | 131 |
| 2021 July | 93 | 48 | 141 |
| 2021 June | 101 | 56 | 157 |
| 2021 May | 163 | 52 | 215 |
| 2021 April | 352 | 137 | 489 |
| 2021 March | 216 | 37 | 253 |
| 2021 February | 123 | 21 | 144 |
| 2021 January | 145 | 25 | 170 |
| 2020 December | 120 | 21 | 141 |
| 2020 November | 109 | 26 | 135 |
| 2020 October | 74 | 14 | 88 |
| 2020 September | 72 | 24 | 96 |
| 2020 August | 90 | 14 | 104 |
| 2020 July | 116 | 26 | 142 |
| 2020 June | 85 | 12 | 97 |
| 2020 May | 203 | 23 | 226 |
| 2020 April | 214 | 20 | 234 |
| 2020 March | 160 | 27 | 187 |
| 2020 February | 149 | 20 | 169 |
| 2020 January | 166 | 18 | 184 |
| 2019 December | 115 | 20 | 135 |
| 2019 November | 148 | 22 | 170 |
| 2019 October | 191 | 21 | 212 |
| 2019 September | 306 | 25 | 331 |
| 2019 August | 281 | 29 | 310 |
| 2019 July | 225 | 25 | 250 |
| 2019 June | 262 | 28 | 290 |
| 2019 May | 276 | 29 | 305 |
| 2019 April | 261 | 25 | 286 |
| 2019 March | 272 | 32 | 304 |
| 2019 February | 223 | 13 | 236 |
| 2019 January | 70 | 19 | 89 |
| 2018 December | 65 | 34 | 99 |
| 2018 November | 82 | 38 | 120 |
| 2018 October | 98 | 19 | 117 |
| 2018 September | 56 | 17 | 73 |
| 2018 August | 4 | 0 | 4 |
| 2018 July | 3 | 0 | 3 |
| 2018 June | 2 | 0 | 2 |
| 2018 May | 0 | 2 | 2 |
| 2018 April | 0 | 21 | 21 |
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