Introduction : Unfortunately, recurrent HCV infection of engraftment is inevitable if the virus was not eradicated in recipients. Because of post-transplantation immunosuppression, if left untreated, HCV infection progresses to cirrhosis early in the post-transplant period. Direct antiviral agents (DAAs) has greatly improved the SVR (sustained virological response) rate, and safety concerns were minimal. Despite that a gray zone of mixed presentation of viral hepatitis with autoimmune hepatitis remains, posing a great challenge.

Methods : 47years old man with living donor liver transplantation in October 2013, remained uneventful and was discharged on mycophenolate, mofetil and tacrolimus. He achieved SVR on Sofosbovir and Ribavirin therapy which was completed in December 2016. After 8 months of DAAs therapy he started noticing itching and mild fatigue , and on follow up he was found to have raised total bilirubin and alkaline phosphatase in December 20117. Although HCV PCR was negative and so was MRCP and other investigations.

Results : His liver biopsy revealed chronic ductopenic rejection with granuloma formation and features of autoimmune hepatitis. His ANA profile was found to be significantly positive. Despite steroids and further immunosuppression he could not manage to recover. He was sent to liver transplant centre for second liver transplant but concerns were reappearance of autoimmune flare and graft failure has limited his
transplant.

Conclusions : This case is an eye opener for the transplant hepatologist and immunologist as autoimmunity remains to be to be a difficult scenario to cope with in transplant
setting. Need powerful immunosuppressant in such cases and more insight into these grey zones.