Coexistence of Anti-CCP Positive Rheumatoid Arthritis with Autoimmune Hepatitis Type 1

Author(s): Bhanu Sharma, Pragyan Paramita Parija, Onjal K. Taywade, Swati Rajput

Anti-cyclic citrullinated peptide (anti-CCP) antibodies are highly specific serological markers for rheumatoid arthritis (RA), providing both diagnostic and prognostic value. Autoimmune hepatitis type 1 (AIH-1), a chronic liver disease, is characterized by positive autoimmune markers such as antinuclear antibodies (ANA) and anti-smooth muscle antibodies (SMA). While musculoskeletal symptoms can occur in autoimmune liver diseases, they are rarely associated with high-titre anti-CCP or fulfil diagnostic criteria for RA. The coexistence of RA and AIH is exceptionally rare and presents diagnostic challenges, especially in distinguishing hepatic arthropathy from true RA. We report a case of a 50-year-old woman with a two-year history of biopsy-confirmed AIH-1, who presented with new-onset symmetrical polyarthritis involving small and large joints. Serologic evaluation revealed rheumatoid factor positivity with extremely elevated anti-CCP levels (>25000 U/mL). Inflammatory markers (ESR, CRP) were significantly raised. Her joint symptoms and laboratory profile met the ACR/EULAR criteria for RA. She was already receiving immunosuppressive therapy for AIH (prednisolone, azathioprine), which was adjusted to accommodate RA management. This case underscores a rare yet clinically significant autoimmune overlap syndrome involving AIH-1 and seropositive RA. High anti-CCP titres in patients with autoimmune liver disease should raise clinical suspicion for true RA rather than hepatic-related arthropathy. Interdisciplinary management involving rheumatologists and hepatologists is essential to ensure early recognition, diagnostic classification, and effective treatment of such patients. This case supports the inclusion of anti-CCP screening in AIH patients presenting with persistent joint complaints.