A 39 year-old female was referred for an abnormal liver profile after she noted scleral icterus, fatigue, and pruritus. She denies alcohol, substance, herbal supplement, or recent antibiotic use. Labs demonstrate an alkaline phosphatase of 462 u/l, AST 277 u/l, ALT 281 u/l, total bilirubin 1.9 mg/dl, direct bilirubin 1.0 mg/dl, INR is normal. Viral serologies were notable for immunity to HAV and HBV and negative HCV antibody. Ultrasonography revealed hepatomegaly and coarsened echotexture. Her primary care provider obtained an ANA in evaluation of a silvery plaque which was elevated to >1:2560 titer. You order several studies which are remarkable for significantly elevated IgG level, positive anti-mitochondrial antibody, and positive anti-smooth muscle antibody.