A Rare Case of Pseudomonas putida Bacteremia in a Patient with Cirrhosis of Liver.

Pseudomonas putida (P. putida) is a rare pathogen that primarily causes nosocomial infection. It is usually seen in immune dysfunction or immunocompromised patients and patients with invasive medical devices. Here, we present a rare case of P. putida bacteremia in a patient with cirrhosis of the liver.

Challenges in Diagnosis of Esophageal Tuberculosis.

Esophageal tuberculosis (TB) is a rare manifestation of extrapulmonary TB, accounting for <0.2% of all TB cases. Esophageal TB most commonly presents with dysphagia, odynophagia, retrosternal pain, and systemic symptoms like decreased appetite, loss of weight, and low-grade fever as associated or other presentations. We report a similar case recently encountered as an elderly male patient presented with chronic dysphagia to solids, loss of appetite, and significant loss of weight. Radiological and endoscopy pictures looked like esophageal cancer with histopathological examination (twice) negative for the same. Diagnosis of esophageal TB was confirmed by GeneXpert Ultra of biopsy sample and histopathological examination was suggestive of granulomatous esophagitis. The patient improved on 6 months antitubercular therapy. The unique aspect of this case was how the lesion mimicked an esophageal carcinoma on imaging which posed a diagnostic challenge.

Efficacy of endoscopic over-the-scope clip fixation for preventing migration of self-expandable metal stents: a systematic review and meta-analysis.

BACKGROUND: Over-the-scope clips (OTSC), both conventional and Stentfix, are believed to anchor the self-expanding metal (SEMS) and prevent migration. We aimed to systematically study the efficacy of endoscopic OTSC fixation of SEMS in prevention of migration. METHODS: We searched electronic databases from inception to November 11, 2022 to identify studies reporting outcomes of OTSC fixation of metal stents. The primary outcome was to calculate the pooled migration rates following OTSC anchorage of SEMS and to compare it with controls (SEMS without any fixation). The secondary outcomes include technical and clinical success of OTSC anchorage of SEMS. Random effect models were used to determine pooled rates of migration and technical as well as clinical success rates of OTSC anchorage of metal stents. RESULTS: A total of 9 studies were included. The pooled rate of migration following OTSC anchorage of SEMS was 0.10 (95%CI, 0.04-0.20, I2 = 43%). The pooled rate of migration following OTSC anchorage of esophageal SEMS was 0.08 (95%CI, 0.04-0.15, I2 = 0%). The pooled risk ratio of SEMS migration following OTSC Stentfix was lower as compared to no fixation of SEMS [RR = 0.24 (95%CI,0.13- 0.43, I2 = 0)]. The pooled technical success rate of OTSC fixation following SEMS was 0.98 (95%CI, 0.81-1.00, I2 = 0%). The pooled clinical success rate of OTSC fixation following SEMS was 0.79 (95%CI, 0.64-0.88, I2 = 56%). All studies had valid and reliable methods to diagnose migration, technical and clinical success. CONCLUSIONS: The use of OTSC clips (conventional or Stentfix) for anchorage had a lower risk of migration of metal stents than no fixation. Future studies should look into prospective multicenter studies on their use to prevent the migration of SEMS.

Early virus clearance of SARS-CoV-2 among co-infection with malaria.

BACKGROUND AND OBJECTIVES: India has witnessed significant number of cases of co-infection of malaria or dengue with COVID-19, especially during the monsoon season. It has been speculated that anti-malarial immunity might have a protective role in co-infection. Retrospective analysis of co-infection of vector-borne diseases with COVID-19 was done for comparing their remission with matched controls with COVID-19 by means of epidemiological data. METHODS: Medical case records of patients with co-infection of malaria or dengue with COVID-19 admitted at TNMC and BYL Nair Charitable Hospital from 1 March 2020 to 31 October 2020 were analyzed retrospectively. Out of 91 cases of co-infection of SARS-CoV-2 infection with vector-borne diseases, virus clearance (VC) analysis was done for 61 co-infections with malaria. RESULTS: Median duration of VC for co-infection with malaria was 8 days whereas, it was 12 days for controls with COVID-19 (p=0.056). Young patients (≤50 years) with co-infection recovered faster than controls age (p=0.018). INTERPRETATION & CONCLUSION: Co-infection with malaria is associated with less severe disease and early recovery in the form of early VC. Genetic and immunological studies are necessary to confirm malaria protection against SARS-CoV-2 infection.

An Audit of Extrahepatic Portal Vein Obstruction: Experience from Tertiary Referral Center.

BACKGROUND: Extrahepatic portal vein obstruction (EHPVO) is a common cause of portal hypertension in India. AIMS: (1) To evaluate the clinical presentation and the natural history of EHPVO; (2) to describe the risk factors, rebleeding rates and development of portal biliopathy on follow-up; and requirement of surgery in EHPVO at a tertiary care center. METHODS: Data from 318 consecutive patients with EHPVO from June 2012 to October 2020 were analyzed. All patients underwent liver biochemistry, ultrasonography (USG) abdomen, upper gastrointestinal (GI) endoscopy, and viral serology. Color Doppler, computed tomography (CT) abdomen and magnetic resonance cholangiopancreatography (MRCP) were done as indicated. RESULTS: Mean age of presentation was 15.08 years [standard deviation (SD) 12.74; 6 months-60 years; 210 males)]. The presenting features were upper GI bleed (n = 227) (age at first bleed 11 years; 4 months-56 years), left hypochondrium pain or lump (n = 67), and only lower GI bleed (n = 1). Incidentally detected EHPVO on USG was seen in 10.69% (n = 34) patients. Postbleed ascites were seen in 10.69% (n = 34) patients. Six patients had symptomatic portal biliopathy and 14 had hypersplenism. Around 14.77% (n = 47) of patients had a history of being delivered at home, while 3.45% (n = 11) had a history of umbilical sepsis. During follow-up, 35.3% (n = 82) of patients had rebled. On imaging, associated splenic vein (SV) collaterals and superior mesenteric vein (SMV) collaterals were seen in 35.84% (n = 114) and 11.01% (n = 35) patients, respectively. Gallbladder varices were seen in 44.3% (n = 106), while gallstones in 5.66% (n = 18). On endoscopy, 87.42% (n = 278) patients had esophageal varices, 18.86% (n = 60) had isolated fundic varices, and three had ectopic varices. Only two patients had rectal varices and colopathy. Emergency devascularization was required in 3.45% (n = 14) patients for the failure of variceal bleed control, 1.88% (n = 7) underwent splenectomy, and four patients had proximal splenorenal shunt (PSRS) surgery. CONCLUSION: Extrahepatic portal hypertension (EHPVO) is an important cause of portal hypertension (PHT) in our country. The majority of them present with GI bleed; postbleed ascites were seen only in ~10%. Rebleed occurs in one-third of cases. Gallbladder varices were common; portal biliopathy occurred in 10% and were usually asymptomatic.

Three-dimensional Bioprinting in Gastroenterology: A Literature Review.

Three-dimensional (3D) bioprinting is one of the most upcoming research areas which apply 3D printing technology in medical and surgical applications. The basic concept of 3D bioprinting is to design tissue scaffolds to replace diseased or injured tissues. Gastroenterology is one of the medical fields in which 3D bioprinting is being rigorously researched. Although attempts are made to design 3D-geometrical constructs, the overall performance is currently hindered by limitations, including material viability and toxicity affecting the clinical outcome. However, further research at the current pace should overcome these limitations, helping open a new horizon in gastroenterology. In this review, we cover all the aspects of 3D bioprinting in gastroenterology with a holistic perspective on its current limitations and future perspectives in clinical applications.

Effects of high bilirubin level in pregnancy in Crigler-Najjar syndrome type 2: An extremely rare but important clinical entity to recognize.

Crigler-Najjar is a rare genetic autosomal recessive disorder caused by deficiency of enzyme Uridine 5-Diphosphate Glucuronosyl Transferase (UDP-GT). We report the case of a 24-year-old female with two consecutive pregnancies with a high level of total bilirubin level of 15.1 mg/dl and a direct bilirubin level of 0.8 mg/dl during the first pregnancy. As she was diagnosed case of Crigler Najjar type 2, she was on phenobarbitone 60 mg daily. With careful monitoring, she continued with the same dose. We concluded that even with high bilirubin level (15.1 mg/dl) in pregnancy, no adverse effects to the baby and mother were seen.

A case of giant colonic lipoma removed endoscopically using a modified hybrid technique.

Colonic lipomas are benign adipose tumors and are mostly asymptomatic. They may cause symptoms when their size becomes more than 2 cm. Giant colonic lipoma (GCL) is a rare finding in endoscopy which presents with or without macroscopic ulceration and may lead to iron deficiency anaemia (IDA). The choice of treatment of symptomatic large colonic lipomas has been controversial. Here we are presenting a case of GCL presenting with occult bleeding causing iron deficiency anaemia (IDA). It was removed endoscopically using a combination of noradrenaline, endoloop ligation, and snare cautery technique (modified hybrid technique). Successful removal of the GCL lead to the resolution of IDA. This case report highlights that even GCL can be removed endoscopically, thus surgery can be prevented. Clinical Significance: GCL is an unusual cause of anemia. Modified hybrid endoscopic removal technique improves safety.

Pattern of liver function test variations in COVID-19 infection & its clinical significance: A study from a dedicated COVID-19 tertiary care centre from India.

Background & objectives: Coronavirus disease 2019 (COVID-19) affects respiratory, gastrointestinal, cardiovascular and other systems disease. Studies describing liver involvement and liver function test (LFT) abnormalities are sparse from our population. This study was undertaken to estimate the LFT abnormalities in patients with COVID-19 in a tertiary care set up in India. Methods: In this retrospective study conducted at a tertiary care centre in Mumbai, India, all consecutive patients with proven COVID-19 by reverse transcriptase-PCR from March 23 to October 31, 2020 were enrolled. Of the 3280 case records profiled, 1474 cases were included in the study. Clinical characteristics, biochemical parameters and outcomes were recorded. Results: Overall 681 (46%) patient had deranged LFTs. Hepatocellular type of injury was most common (93%). Patients with deranged LFTs had more probability of developing severe disease (P<0.001) and mortality (P<0.001). Advanced age (P<0.001), male gender (P<0.001), diabetes mellitus (P<0.001), lower oxygen saturation levels at admission (P<0.001), higher neutrophil-lymphocyte ratio (P<0.001), history of diabetes mellitus and cirrhosiss were associated with deranged LFTs. Acute liver injury was seen in 65 (4.3%) cases on admission and 57 (3.5%) cases during hospital stay. On multivariate analysis for predicting mortality, age >60 yr serum creatinine >2 mg%, PaO2/FiO2 ratio ≤200 and raised AST >50 IU/l (OR: 2.34, CI: 1.59-3.48, P<0.001) were found to be significant. Interpretation & conclusions: In COVID-19, LFT abnormalities were common, and derangement increased as severity progressed. The presence of deranged LFT worsens the clinical outcome and predicts in-hospital mortality.

Artificial Intelligence in Medicine.

Artificial intelligence as the name suggests is intelligence given to machines by man. AI learns and performs like humans without human instructions. We encounter AI in daily activities, like music and video suggestions in video applications, and personalize what we see on Facebook, Twitter, Instagram. AI makes our day-to-day life easier, efficient and it increases the speed and accuracy of our efforts. In this article, we reviewed previous articles and internet sites to understand the general principles of artificial intelligence. We included general articles and few articles related to medicine to understand the basics of AI and its application in the medical field. A literature search was done using the following search terms: 'AI' and 'AI in medicine'.

Gallbladder Polyp: Review and Proposed Algorithm for Management.

Gall bladder polyp is a lesion which is often an incidentally reported finding on ultrasonography. Such patients may or may not have symptoms of gall bladder disease. Although majority of polyps are cholesterol polyps, some are malignant. The challenge is early detection of malignant polyp and cholecystectomy before it becomes invasive or if invasive to carry out adequately wide surgical excision; while avoiding surgery in asymptomatic patients with benign disease. Following are the characteristics suggestive of malignancy in polyp: - size more than 10 mm, solitary lesions, increase in size over time, adenomatous polyps, sessile lesions and associated gallbladder wall thickening. Incidence of malignancy is higher in patients with Indian ethnicity, age more than 50 years, associated primary sclerosing cholangitis or gall stone disease. Pre-operative tissue diagnosis is difficult to obtain and review ultrasonography, contrast enhanced CT scan, endo sonography and a regular follow-up can help the surgeon take the appropriate decision.

Spontaneous Ascitic Fluid Infection: Are we Experiencing an Epidemiological shift in Causative Organisms?

BACKGROUND: Spontaneous ascitic fluid infection (SAI) is common in cirrhotic patients leading to significant morbidity and mortality. Third-generation cephalosporins are currently recommended as first-line therapy. This is a retrospective observational study that aims to determine bacterial etiology, susceptibility patterns of SAI, and its correlation with model for end-stage liver disease-sodium (MELD-Na) and Child-Turcotte-Pugh (CTP) score. MATERIALS AND METHODS: The present study was conducted on 274 consecutive cases admitted in Bombay Hospital and Medical Research Centre, Mumbai, India. Cases of cirrhosis (irrespective of etiology) with ascites between the ages of 18-85 years were included in this study. Ascitic fluid of every patient was aspirated under all aseptic measures and was sent for biochemical, culture, and cytological analysis. RESULTS: Of the 274 patients studied, 34 (12.4%) patients were diagnosed to have SAI. Culture-negative neutrocytic ascites (CNNA) was present in 27 patients, spontaneous bacterial peritonitis (SBP) was present in six patients, and monomicrobial bacteriascites was seen in one patient. Mean age of patients enrolled was 56.05 ± 2.47 years. Eighty-two percent were males and 18% were females. Alcohol (45.45%) was the leading cause of cirrhosis followed by nonalcoholic steatohepatitis (NASH) related cirrhosis (26.47.7%) and hepatitis C virus (HCV) related cirrhosis (11.46%) and cryptogenic cirrhosis (8.82%). Average MELD-Na score was 25 and the CTP class C was most common. Klebsiella pneumoniae was the most commonly isolated organism followed by Escherichia coli. The various factors that predispose to development of SBP include low ascitic fluid protein concentration, a high level of serum bilirubin, deranged serum creatinine, high Child-Pugh score, and high MELD-Na score. CONCLUSION: Ascitic fluid analysis remains the single most important test for identifying and assessing a course of SBP. Early diagnosis and treatment will reduce the mortality rate in these patients.

Thiopurine-induced Myelosuppression with Severe Sepsis in a Patient with Crohn's Disease: A Case Report.

Thiopurines by their glucocorticoid-sparing property help in maintaining remission for patients with inflammatory bowel disease (IBD), when glucocorticoids are reduced and withdrawn. However, due to bone marrow suppression, it cannot be used in various conditions where it is indicated. A 17-year-old patient presented with pancytopenia with neutropenic sepsis and alopecia after 3 weeks of starting azathioprine for her underlying Crohn's disease. Thiopurine S-methyltransferase (TPMT;*2, *3A, *3C) analysis resulted in a wild-type genotype, whereas homozygous Nudix hydrolase 15 (NUDT 15 C415T) variant was positive. Azathioprine was stopped immediately, and she was started on broad-spectrum antibiotics that led to some clinical improvements initially, but later on, the patient developed intestinal obstruction along with postoperative complications leading to death. In this report, we highlight a case of serious hematological toxicity associated with azathioprine use in a patient with Crohn's disease with homozygous NUDT 15 variant, thus favoring the implementation of a pharmacogenomic approach before starting azathioprine, particularly in the Asian population. HOW TO CITE THIS ARTICLE: Debnath P, Nair S, Jain S, Udgirkar S, Contractor Q, Rathi P. Thiopurine-induced Myelosuppression with Severe Sepsis in a Patient with Crohn's Disease: A Case Report. Indian J Crit Care Med 2021;25(2):228-230. PRIOR PRESENTATION OF CASE REPORT AT PROFESSIONAL MEETING: The case was presented in abstract form at the American College of Gastroenterology Annual Scientific Meeting, held at San Antonio, TX, USA 2019. INFORMED CONSENT FOR PUBLICATION OF CASE DETAILS: Obtained from patient's relatives.

Study and Comparison of Metabolic Profile of Lean and Obese Subjects with Non Alcoholic Fatty Liver Disease.

BACKGROUND AND OBJECTIVE: Nonalcoholic fatty liver disease (NAFLD) is conventionally considered to be a disease of obese subjects. Recent data suggests increasing incidence of NAFLD among lean subjects also. The aim of this study was to evaluate the metabolic profile of lean subjects with NAFLD and compare it with obese subjects with NAFLD. We also aimed to compare the same with lean subjects without NAFLD. METHODS: This study included 250 subjects with NAFLD and 500 non-NAFLD controls. Clinical, anthropological and biochemical data were collected. Subjects with body mass index (BMI) >= 25 kg/m2 were taken as obese and subjects with BMI <25 kg/m2 were taken as lean. Study population was divided into four groups i.e. lean subjects with NAFLD (LN), obese subjects with NAFLD (ON), lean subjects without NAFLD (LNN) and obese subjects without NAFLD (ONN). RESULTS: Out of 250 NAFLD subjects, 69 (27.6%) were lean. Out of 69 lean subjects with NAFLD, 54 (78.3%) were having diabetes mellitus. Metabolic profile (including lipid profile, diabetic profile) of lean subjects with NAFLD was significantly abnormal in comparison to lean non-NAFLD subjects. Proportion of subjects with metabolic syndrome was also comparable in both lean and obese NAFLD groups. Despite having comparable BMI, LN groups had significantly higher waist circumference (WC) than LNN. Mean total cholesterol, triglyceride, LDL were significantly higher in obese NAFLD in comparison to lean NAFLD. Mean HDL and VLDL were comparable among both groups. Mean FBS, HbA1c, fasting insulin and HOMA-IR were significantly higher among lean NAFLD group in comparison to obese NAFLD group. Obese NAFLD group had significantly higher levels of SGPT and SGOT as compared to lean NAFLD group. CONCLUSION: Lean NAFLD has significantly higher WC in comparison to non-NAFLD counterparts suggesting possible association with central adiposity. Lean and obese NAFLD share common set of metabolic abnormalities, albeit with varying intensity. Lean NAFLD has more severe insulin resistance in comparison to obese NAFLD. Lean NAFLD subjects appeared to have less severe transaminasemia.

Diarrhoea, Hyperpigmentation and Hamartomatous Polyposis Syndrome.

Cronkhite-Canada syndrome (CCS)is a rare non-hereditary hamartomatous polyposis syndrome of unknown aetiology. It is characterized by diffuse gastrointestinal polyps, dystrophic nail changes, alopecia, cutaneous hyperpigmentation, chronic diarrhoea, anorexia and hypogeusia. It is associated with a high incidence of gastrointestinal malignancies, mortality and morbidity. Early clinical suspicion and treatment is important. We report an elderly male with CCS who showed clinical and endoscopic improvement with long term corticosteroid therapy.

Factors Differentiating Acute Hepatitis B from Acute Exacerbation of Chronic Hepatitis B in Prospective-retrospective Cohort.

INTRODUCTION AND AIM: It is difficult to distinguish acute hepatitis B (AVH-B) from chronic hepatitis B with an acute exacerbation (CHB-AE) in patients whose prior history of HBV infection is unknown. The present study aimed to screen laboratory parameters at presentation to discriminate between these two conditions. MATERIALS AND METHODS: A prospective study was conducted in patients presenting clinically as AVH-B without known previous chronic hepatitis B status. Patients were divided into AVH-B and CHB-AE at end of six months follow up. Clinical and laboratory profiles were compared between these two groups at presentation. RESULTS: There was no significant difference in clinical presentation and risk factors profile in patients of both the groups. Mean age of presentation in AVH-B was 31.8 ± 14.9 years while, 47.2 ±17.3 years in CHB-AE group (p=0.005). Mean IgM anti-HBc levels were higher in AVH-B than in the CHB-AE group (p=0.001). Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of IgM anti-HBc [>12.14 S/CO (Sample/Cut-off )] for diagnosis of AVH-B was 76.9%, 71.4%, 76.9% and 71.4 % respectively. Quantitative HBV DNA levels were significantly higher in CHB-AE group than in AVH-B group (p=0.015). Sensitivity, specificity, PPV and NPV of HBV DNA ( > 15390 IU/ml) for diagnosis of CHB-AE was 78.6%, 46.2%, 44% and 80% respectively. CONCLUSION: A high percentage of patients with apparent AVH-B might be cases of CHB-AE. Elderly patient (mean 47.2 years), high titers of HBV DNA (>15390 IU/ mL) and low IgM anti-HBc titer (<12.14 S/CO) favours CHB-AE over AVH-B.

Massive Lower Gastrointestinal Bleeding Due to Fulminant Necrotizing Amebic Colitis: A Diagnostic and Therapeutic Challenge.

Acute fulminant necrotizing amebic colitis rarely presents with massive lifethreatening lower gastrointestinal bleeding without diarrhea. Diagnosis is difficult as colonoscopy is suboptimal due to active bleeding, stool testing is often negative and a positive serology cannot confirm the diagnosis. We herein report a case of a 39-year-old male who presented with profuse bleeding per rectum, without associated significant antecedent history of fever or diarrhea. Colonoscopy was inconclusive as active bleeding obscured the vision. Computed tomography of abdomen revealed non-specific thickening of the caecum. Emergency laparotomy with right hemicolectomy and temporary ileostomy was performed. Microscopic examination of colonic mucosa revealed Entamoeba histolytica trophozoites with erythrophagocytosis suggestive of fulminant amebic colitis. Intravenous metronidazole was given subsequently and patient recovered completely. Ileocolonic anastomosis was done after closing the ileostomy three months later. This case highlights this exceedingly rare presentation of fulminant amebic colitis which poses a diagnostic challenge and can be life threatening without early surgical intervention.

An Expert Review and Recommendations on the Rational Use of Proton Pump Inhibitors: Indian Perspective.

BACKGROUND: Proton pump inhibitors (PPIs) are the mainstay of treatment for acid peptic diseases (APDs), but are often irrationally prescribed in clinical practice. Appropriate prescription of PPIs is needed to optimize outcomes, and minimize risks and cost burden on the healthcare system. OBJECTIVE: To review available literature on efficacy and safety of proton pump inhibitors (PPIs) and give recommendations for rational use of PPIs from an Indian perspective. METHODS: Twelve healthcare professionals (9 gastroenterologists, 1 cardiologist, 1 orthopedist, 1 clinical pharmacologist) comprised the expert group; members disclosed conflicts of interest. The creation of the expert review was through a process that included meetings (in-person, online, telephone) where each professional contributed their experiences with regards to efficacy and safety of PPIs. Articles published between the years 2000 and 2017 were reviewed for evaluation of safety and efficacy of PPIs in treatment of various APDs. CONCLUSION: This expert review provides key recommendations for decision making in order to minimize the irrational use of PPIs. Some significant recommendations include: patients with GERD and acid-related complications should take a PPI for minimum 12 weeks for healing of esophagitis, and for maximum up to 48 weeks for symptom control. Patients with Barrett's esophagus should take long-term PPI. Patients at high risk for ulcer-related bleeding from NSAIDs including aspirin should take a PPI if they continue to take NSAIDs. Best practice recommendations are meant to merely assist with decision making in conjunction with patients' clinical history, and are not intended to dictate mandatory rules.

Duodenal and Bile Duct Narrowing Due to Partial Annular Pancreas: A Rare Association.

Annular pancreas consists of a ring of pancreatic tissue partially or completely encircling the descending duodenum. It is an unusual congenital anomaly rarely detected in adult life. Gastric outlet obstruction is most common presentation mainly in 2nd or 3rd decades of life. We are reporting an unusual association of partial annular pancreas - a dilated biliary system due to distal common bile duct (CBD) stricture without features of pancreatitis or underlying malignancy which is rare and not reported previously .Our patient also had gastric outflow obstruction. This may be explained by the pancreatic tissue encircling the duodenum at the level where CBD joins the papilla causing dilated CBD and duodenal stenosis.

Natural History and Treatment Outcomes of Severe Autoimmune Hepatitis.

GOALS: The aim of this study was to analyze the natural history and treatment outcomes of autoimmune hepatitis (AIH) variants presenting with severe-AIH. BACKGROUND: Severe acute presentation is an uncommon manifestation of AIH, and it remains poorly characterized. MATERIALS AND METHODS: We included 101 patients with AIH from January 2011 to December 2015. Patients were classified as seropositive-AIH and seronegative-AIH. Patients with acute liver failure, acute-on-chronic liver failure, and severe acute hepatitis were defined as severe-AIH patients. Patient characteristics and treatment outcomes with follow-up until 12 months were analyzed between the different groups. RESULTS: Out of 101 cases, 24 (23.76%) had severe AIH. Of them 9 (37.5%) had severe acute hepatitis, 3 (12.5%) had acute liver failure, and 12 (50%) had acute-on-chronic liver failure. Seronegative-AIH patients presented with severe-AIH significantly more frequently compared with seropositive-AIH patients (50% vs. 20.27%, P=0.022). Severe-AIH had 50% complete responders, 25% partial responders, and 25% treatment failures. Jaundice (88.88% vs. 68.7%, P=0.048), encephalopathy (55.55% vs. 6.66%, P=0.014), and higher international normalized ratio values (2.17±0.60 vs. 1.82±0.14, P=0.038) were factors associated with nonresponse rather than the presence or absence of autoantibodies in severe-AIH. The hazard ratio for predicting remission in the non-severe AIH group as compared with the severe-AIH group was 1.502, which was statistically not significant (95% CI, 0.799-2.827; P=0.205). CONCLUSION: Approximately 24% of patients with AIH have severe-AIH. Conventional autoantibodies are often absent in severe-AIH; however, it does not alter the outcome. Immunosuppressants should be given expediently in patients with severe-AIH.