Bacterial Peritonitis With Acute Liver Failure Secondary to Metastatic Melanoma

Abstract

There are an estimated 76,380 new cases of melanoma with 10,130 attributed deaths in 2016. If detected early before metastasis, surgical resection can provide definitive treatment. We present a patient with the new diagnosis of metastatic melanoma who initially presented with bacterial peritonitis and subsequently developed acute liver failure. A 78-year old man was admitted for concerns of altered mental status and intractable abdominal pain. On assessment he was tachycardic, hypertensive, and had an enlarged abdomen with new tense ascites present. Skin examination was notable for a black lesion on his left arm. CT imaging showed multiple hypodensities in the liver concerning for malignancy (Figure A). Laboratory work up was significant for a leukocyte count of 25,000, Lactate Dehydrogenase (LDH) of 2430, alanine aminotransferase of 149, aspartate aminotransferase of 508, direct bilirubin of 5.2, INR of 1.5, and albumin of 2.3. Peritoneal fluid showed 1800 polymorphonucleated (PMN) cells, LDH of 399, and an albumin of 0.95. He was treated with broad-spectrum antibiotics and resuscitated with intravenous albumin due to concerns of spontaneous bacterial peritonitis. An MRCP showed lesions in the vertebral bodies and a cirrhotic configuration of the liver with nodules throughout (Figure C). A fine needle aspiration of the liver revealed malignant cells with abundant melanin pigment (Figure D, upper left). There were nests of malignant cells with prominent nucleoli and cytoplasmic melanin pigment on core biopsy (Figure D, upper right). These cells showed reactivity with Melan A (Figure D, lower left) and S100 (Figure D, lower right), confirming the diagnoses of melanoma. The patient's clinical status deteriorated despite antibiotics and fluid resuscitation. He elected to be discharged from the hospital with hospice services. In the previously reported cases of hepatic failure secondary to metastatic melanoma, patients presented to the hospital due to abdominal pain, weight loss, jaundice, or lethargy. There is also an association with fulminant liver failure and elevated LDH, as was noted in this patient. This case was unique and presented a clinical dilemma as the patient had no risk factors for cirrhosis, but presented with bacterial peritonitis and liver failure. It was the combination of both skin examination and liver biopsy that alluded to the idea of metastatic melanoma.Figure: CT scan showing multiple hypodensities throughout the liver and spleen.Figure: (Upper Left): Papanicolaou stain, 40x magnification: Discohesive, malignant cells with abundant melanin pigment, suggestive of metastatic melanoma. (Upper Right): H&E stain, 40x magnification: Nests of malignant cells with prominent nucleoli and cytoplasmic melanin pigment. (Lower Left): Melan A stain, 40x magnification: Tumor cells express strong, diffuse reactivity with Melan A. (Lower Right): S-100 stain, 40x magnification: Tumor cells express focal reactivity with S-100.Figure: MRCP imaging revealing multiple liver nodules and a cirrhotic configuration of the liver.