Moffitt Pearls 11.3.17 – Saipan Case
Thank you to Amy for presenting a case from Saipan!! We learned about a middle-aged man presenting with encephalopathy and jaundice found to have acute liver injury and renal failure of unclear etiology. The leading thoughts were possibly leptospirosis vs biliary colic that self resolved. The patient was managed with IV abx and IVFs and improved over 2 weeks. We discussed the limitations of practicing in this setting and inability to transfer this patient to a center for transplant evaluation.
- EtoH Hepatitis: jaundice, anorexia, fever, and tender hepatomegaly. Labs: transaminases (typically less than 300 int. unit/mL), AST/ALT ratio > 2. Patients may also present with right upper-quadrant/epigastric pain, hepatic encephalopathy, and signs of malnutrition.
- Acute liver failure is defined as the presence of coagulopathy (INR > 1.5), encephalopathy and no pre-existing liver disease. See more details below.
- Leptospirosis has a broad range of manifestations, from subclinical illness or mild self-limited disease (approximately 90% of infections) to Weil’s syndrome (Weil’s disease), which is characterized by renal failure, jaundice, and hemorrhage and has a 5 to 15% mortality rate (1).
- See this NEJM article where HH crushes the diagnosis in the first couple of sentences (it is related to this case)
Overview of Acute Liver Failure
ALF = coaguapathy INR > 1.5, encephalopathy, and no signs of chronic liver disease
- IVDU, travel, sexual, ingestions, Fmhx Wilson’s, (note: Hemochromatosis – no acute liver failure)
- Vitals, stigmata of liver disease, neuro exam, optho exam
Etiology of Acute Liver Failure
- Toxins* – Tylenol (most common cause in USA), Amanita
- Acute viral hepatitis*
- Professional: HAV, HBV, sometimes HCV, HEV
- “Moonlighters”: HSV, CMV, VZV, parvovirus
- Autoimmune Hepatitis
- Acute Budd Chiari – esp if concomitant portal vein thrombosis
- Reactivation of HBV or HDV on chronic HBV
- Wilsonian crisis – often with concomitant hemolytic anemia
- Malignant infiltration – breast, small cell lung, lymphoma, melanoma, myeloma
- Heat stroke
- Remember -> NOT causes of acute liver failure – ETOH, NAFLD, iron overload, alpha-1 def, PSC, PBC
- * denotes are most likely to cause AST/ALT in the 1000s
Moffitt Pearls 11/6 – Toxic Ingestions
Thank you to Tim for presenting a fascinating case of a young woman 9 weeks post-partum presenting with a profound gap acidosis and osm gap initially c/f ethylene glycol vs methanol ingestion found to have severe starvation ketosis. We discussed the evaluation of possible ingestions and treatment for suspected Ethylenel Glycol ingestion with fomepizole (below).
Thank you HH for presenting a mini-case of a young engineer returning from India p/w abdominal pain, n/v and mild hepatocellular transaminitis (300s) found to have mesenteric lymphadenopathy 2/2 hepatitis E!!
- Per EM guidelines send Serum Osm, Salicylates, APAP and EtoH levels in any suspected ingestion.
- Fomepizole is used in ethylene glycol and methanol toxic ingestion. It is a competitive inhibitor of alcohol dehydrogenase and prevents formation of glycolic acid which is responsible for both the acidosis and oxalate crystal formation. See this NEJM article for more info.
- We learned the ddx for mesenteric lymphadenopathy include hepatitis E in addition to those listed below!!
Effect of Fomepizole on Metabolism of Eythlene Glycol and Methanol (Brent J. N Engl J Med 2009;360:2216-2223)
Differential Diagnosis for Mesenteric Lymphadenopathy
- Malignancy – almost any intraabdominal malignancy and metastatic process can cause mesenteric lymphadenopathy, however the following are more common:
- Carcionid Tumors
- Kaposi Sarcoma
- Carcinoma of pancreas, colon or small bowel
- TB or MAC
- Salmonella and Yersinia
- T. Whippelii
- Viral Infections –EBV and Hepatitis E