What Is Causing This Patientʼs Acute Liver Failure

Abstract

Introduction: Acute liver failure remains one of the most difficult challenges in ever day medicine. This case describes an acute and unusual presentation of a rare cause of acute liver failure. Case presentation: A 61 year old male presented with 3 weeks complain of worsening lower extremities edema and right upper quadrant (RUQ) pain. Past medical history consists of chronic back pain and hypertension. He is a previous heavy smoker with 45 pack year. He does not abuse alcohol. Initial vital signs were within normal range. Physical examination showed jaundice, hepatomegaly, RUQ tenderness and bilateral pretibial edema. Liver function tests were significant for rapid deterioration over the course of 12 days of hospitalization. T.bilirubin raises from 2.3 to 8.9 (direct up to 7.4), progressive rise of ALT up to 350 IU/l, AST up to 207 IU/l, ALP at 368 IU/l and ammonia of 137 mcg/dl. PT/INR and acetaminophen level were normal. Viral and autoimmune serologies were negative. Ferritin was high at 1915 mcg/L along with high ferritin saturation at 63%. CT chest revealed 2 nonspecific ground glass opacities in the left upper lobe, the largest was 2.2cm. CT abdomen revealed hepatomegaly without any intrahepatic nodular lesions. Abdominal US with Doppler showed 7 mm gall bladder wall thickness and normal hepatic and portal venous blood flow. MRCP was unremarkable. Transcutaneous liver biopsy was performed for further evaluation of worsening LFTs and revealed metastatic small cell carcinoma. Patient subsequently deteriorated with further worsening of liver function test and development of hepatic encephalopathy. Family decided on comfort measures and patient died 12 days after hospitalization. Discussion Fulminant hepatic failure (FHF) is characterized by the development of severe liver injury with impaired synthetic capacity and encephalopathy in patients with previous normal liver. Most common causes are viral hepatitis, drug toxicity, ischemia or vascular thrombosis. Malignancy causing acute hepatic failure is rare but must be considered to avoid inappropriate referral for transplantation. There have been reported cases of Small Cell lung Carcinoma presenting as FHF. In some of them the diagnosis of metastasis to liver were made histologically after death with no nodular lesions visible in the liver using a contrast-enhanced CT scan. However, there have been reported cases of Extra Pulmonary Small Cell Cancer which could be the case in this patient.