Acute Liver Failure From Small Cell Carcinoma of the Lung

Abstract

Acute liver failure (ALF) is characterized by liver damage along with encephalopathy and encephalopathy in patients without any prior history of liver disease. It is most commonly associated with acetaminophen hepatotoxicity, viral hepatitis or ischemic injury. Malignant infiltration has also been described as a cause of ALF, but small cell carcinoma (SCC) of the lung is an uncommon etiology. Here, we describe a patient who was admitted with ALF and was revealed to have SCC of the lung. A 75-year-old woman who had undergone elective laparoscopic cholecystectomy three weeks prior for symptomatic cholelithiasis presented with encephalopathy, abdominal pain and abnormal liver enzymes including AST 118, ALT 79, alkaline phosphatase 260, total bilirubin 3.8, direct bilirubin 2.8 and INR 1.7. Serologic evaluation of liver dysfunction was unremarkable including hepatitis testing, drug levels, infectious work-up, and chronic liver disease testing. Abdominal doppler was normal. CT scan of the abdomen showed hepatomegaly with a large area of decreased attenuation in the left lobe of the liver. Hepatomegaly with a mottled appearing liver and infiltrative signal abnormality in the lateral segment of the left lobe of the liver was observed on MRCP. Hepatic mass biopsy revealed small cell carcinoma, favoring lung primary. Given her poor performance status and liver failure, she was deemed not a candidate for chemotherapy and hospice care was pursued; she ultimately died 10 days after admission. Malignant infiltration of the liver from SCC of the lung has been described due to its aggressive nature to metastasize to other organs, but it is unusual for SCC to manifest as ALF. Prompt liver biopsy with a rapid immunostaining is essential to establish a diagnosis so that chemotherapy may be started. In our patient, evaluation for common causes of ALF was negative making malignant infiltration from SCC the likely etiology. Our case is unique from prior reports of ALF due to SCC of the lung in that it did not reveal significantly elevated aminotransferase levels but had other hallmark features of ALF including elevated bilirubin, INR and encephalopathy. Additionally, the temporal relation to the recent cholecystectomy prompted testing for surgical complications and questioning whether the initial presentation was indeed secondary to symptomatic cholelithiasis. This case demonstrates that malignancy, particularly SCC of the lung, should be considered in patients with ALF.Figure: Large vague area of decreased attenuation in the lateral segment of the left lobe of the liver on CT.Figure: Signal abnormality in the lateral segment of the left lobe of the liver on MRCP.