Fulminant Liver Failure From Infiltrative Carcinomatosis

Abstract

Introduction: Malignancy is a rare cause of fulminant liver failure. We report a case of infiltrative carcinomatosis of unknown origin, presenting as acute liver failure (ALF) and progressing to fulminant liver failure (FLF). Case Presentation: 58—year—old Caucasian male presented with worsening encephalopathy along with abdominal pain, distension and peripheral edema for three months. Physical exam was significant for icterus, ascites and hepatomegaly. Computed tomography of abdomen revealed a nodular liver with small hypo attenuating lesions. Initial work up was significant for serum ammonia of 227 ug/dl, INR of 3.6, total bilirubin of 13.1, AST >10,000, and ALT of 4900, Factor VII levels of 7%, qualifying as ALF; associated with refractory hyperkalemia requiring emergent dialysis. His hospital course was complicated by hematemesis and worsening ascites requiring therapeutic paracentesis. In the interim, biochemical parameters worsened further with Factor V and VII levels at 12% and 7%, INR of 9.5 and lactate dehydrogenase of 7000 U/L, lactic acidosis, hypoglycemia and Grade IV encephalopathy, reflective of FLF. Patient subsequently required mechanical ventilation and vasopressor support. Furthermore, he developed abdominal compartment syndrome, at which point, patient was made comfort care as per wishes of next of kin. A limited abdominal autopsy revealed near total hepatic necrosis, associated with infiltrating pancytokeratin positive carcinoma cells. A primary could not be determined due to lack of examination of other organs.3028_A.tif Figure 1: H&E staining of liver specimen showing massive hepatic necrosis secondary to extensive tumor thrombus3028_B.tif Figure 2: Liver biopsy staining as pancytokeratin positive, supportive of the primary tumor being of epithelial subtype.3028_C.tif Figure 3: Liver specimen with Hep PAR Immunohistochemical staining positiveDiscussion: Liver is one of the most common sites for metastasis of various cancers. FLF due to metastasis has been rarely reported. Imaging findings are non—specific and diagnosis is mostly confirmed by autopsy. A loss of adhesion molecules in the primary tumor allows migration of cells to organs including liver, with an intra—sinusoidal pattern of invasion rather than parenchymal mass formation. The occlusion of blood vessels results in massive parenchymal necrosis. Liver transplantation is contra—indicated in these cases, with most chemotherapy agents not being viable options due to severe liver dysfunction. The prognosis is dismal with death occurring between 3 days to 6 months. In conclusion, we report a rare case of FLF secondary to infiltrative carcinomatosis. Physicians should have a high index of suspicion to consider this etiology when approaching a case of ALF so as to avoid inappropriate listing for transplantation.