I have a triple infected patient with HIV/HCV/HBV. His ALT and AST are elevated. He has a previously reactive PPD skin test, but no evidence of active pulmonary TB. He is not on HAART therapy due to stable CD4 ct > 350 and HIV RNA < 55,000 copies/mL. An autoimmune profile is abnormal and suggestive of Sjogren's syndrome. His liver biopsy reveals a diffuse, dense lymphocytic infiltrate. His AFP and abdominal ultrasound are normal. Will treatment of his HCV with PegIFN/ribavirin make his autoimmune liver disease worse? Would you treat him for autoimmune liver disease with steroids in light of his reactive PPD skin test? Thank you for your consideration.
 

Very tough situation. the histology you describe sounds considerably more like an autoimmune picture than an HCV picture, although there can be overlap between these entities. i would have the histology reviewed with your liver pathologist/hepatologist, and try to pin them down on the severity. if HCV seems a possiblity to explain the histology, a very cautious trial of IFN should be considered. you should also assess HBV staining as well to determine its contribution if any. please feel free to correspond back. as you have already stated, the risks of steroids are not trivial.