Unexpected spotlight on two unusual substances

AbstractAcute liver failure (ALF) is a rare and unexpected condition, which is commonly related to drug ingestion and viral infections. Here, two ALF fatalities are presented, which showed a rapid progression between the onset of symptoms and death. Both cases gained attention as unusual substances were suspected to be the reason for the fatal ALF, namely the prescription-free natural remedy Iberogast® (Bayer Vital GmbH, Leverkusen, Germany) and freely available energy drinks. Autopsy findings revealed that the fatal ALFs were unrelated to the ingestion of these two substances.

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Acute Fulminant Hepatic Failure in a Woman Treated With Phenytoin and Trimethoprim-Sulfamethoxazole

Archives of Pathology & Laboratory Medicine ◽

10.5858/2000-124-1800-afhfia ◽

2000 ◽

Vol 124 (12) ◽

pp. 1800-1803 ◽

Cited By ~ 1

Author(s):

Marius J-M. Ilario ◽

Jose E. Ruiz ◽

Constantine A. Axiotis

Keyword(s):

Liver Injury ◽

Liver Failure ◽

Acute Liver Failure ◽

Fulminant Hepatic Failure ◽

Hepatic Failure ◽

Acute Hepatic Failure ◽

Hepatic Necrosis ◽

Rare Occurrence ◽

Autopsy Findings ◽

Massive Hepatic Necrosis

Abstract Massive hepatic necrosis following exposure to phenytoin and trimethoprim-sulfamethoxazole is a rare occurrence and to the best of our knowledge has not been reported previously. Acute hepatic failure following administration of trimethoprim-sulfamethoxazole has rarely been seen, and only 4 cases have been well documented pathologically. We report a case of acute liver failure in a 60-year-old woman following ingestion of phenytoin and trimethoprim-sulfamethoxazole concomitantly over a 9-day period. Autopsy findings revealed acute fulminant hepatic failure. This case demonstrates the effects of chemical-chemical interactions in the potentiation of hepatotoxicity of single agents and specifically illustrates the need for discontinuing trimethoprim-sulfamethoxazole in the presence of early liver injury.

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Clinical features, laboratory characteristics and outcome of patients with drug-induced acute liver failure

International Journal of Advances in Medicine ◽

10.18203/2349-3933.ijam20191168 ◽

2019 ◽

Vol 6 (2) ◽

pp. 515

Author(s):

Tauseef Nabi ◽

Nadeema Rafiq ◽

Imran Jamil ◽

Quratul Ain Arifa

Keyword(s):

Liver Failure ◽

Acute Liver Failure ◽

Hospital Stay ◽

Clinical Features ◽

Geographical Area ◽

Length Of Hospital Stay ◽

Medical Emergency ◽

Rapid Progression ◽

Middle Aged ◽

Drug Induced

Background: Acute liver failure (ALF) is a rare medical emergency. Its rapid progression and high mortality demand early diagnosis and expert management. Drug-induced ALF (DI-ALF) remains the uncommon cause of ALF in India. Clinical and etiological profile varies with geographical area and time. A prospective study of DI-ALF was carried with the aim to determine the clinical features, laboratory characteristics, outcome and hospital course.Methods: A total of 15 patients with a diagnosis of DI-ALF were included in the study. The variables evaluated were demographic, signs and symptoms, biochemical parameters [bilirubin, alanine aminotransferase (ALT), aspartate aminotransferase (AST), prothrombin time (PT), internal normalization ratio (INR) etc.], outcome and course during hospitalization.Results: Out of 15 DI-ALF patients, 12 had Anti-tuberculosis therapy (ATT) induced ALF and 3 patients had ayurvedic induced ALF. Majority of the patients were females (73.3%) and middle-aged (42.60±14.30 years). Coma grade at the time of admission showed that majority of patients (66.8%) had grade I and II encephalopathy. Depending on the pattern of liver injury, hepatocellular pattern was most common (53.3%) followed by mixed and cholestatic pattern. 40% of patients died with DI-ALF complications of which ATT induced ALF contributed 41.7%. Mean AST was more increased as compared to ALT. Development of ascites (P = 0.030) and mannitol use (P = 0.025) was significantly more common in non survived group than survived group. Length of hospital stay was significantly more in non survived group than survived group (P = 0.009).Conclusions: ATT was the class of drugs most frequently associated with DI-ALF. DI-ALF disproportionately affected middle-aged women. Most DILI ALF patients had hepatocellular injury pattern. 40% of patients died with DI-ALF complications. Development of ascites, mannitol use and length of hospital stay was significantly more in non survived group than survived group.

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HELLP Syndrome or Acute Fatty Liver of Pregnancy: A Differential Diagnostic Challenge

Geburtshilfe und Frauenheilkunde ◽

10.1055/a-1091-8630 ◽

2020 ◽

Vol 80 (05) ◽

pp. 499-507

Author(s):

Werner Rath ◽

Panagiotis Tsikouras ◽

Patrick Stelzl

Keyword(s):

Liver Failure ◽

Fatty Liver ◽

Acute Liver Failure ◽

Hellp Syndrome ◽

Multiple Pregnancy ◽

Rapid Progression ◽

Laboratory Findings ◽

Mitochondrial Fatty Acid ◽

Increased Risk ◽

Acute Fatty Liver

AbstractHELLP syndrome and the less common acute fatty liver of pregnancy (AFL) are unpredictable, life-threatening complications of pregnancy. The similarities in their clinical and laboratory presentations are often challenging for the obstetrician when making a differential diagnosis. Both diseases are characterised by microvesicular steatosis of varying degrees of severity. A specific risk profile does not exist for either of the entities. Genetic defects in mitochondrial fatty acid oxidation and multiple pregnancy are considered to be common predisposing factors. The diagnosis of AFL is based on a combination of clinical symptoms and laboratory findings. The Swansea criteria have been proposed as a diagnostic tool for orientation. HELLP syndrome is a laboratory diagnosis based on the triad of haemolysis, elevated aminotransferase levels and a platelet count < 100 G/l. Generalised malaise, nausea, vomiting and abdominal pain are common symptoms of both diseases, making early diagnosis difficult. Clinical differences include a lack of polydipsia/polyuria in HELLP syndrome, while jaundice is more common and more pronounced in AFL, there is a lower incidence of hypertension and proteinuria, and patients with AFL may develop encephalopathy with rapid progression to acute liver failure. In contrast, neurological symptoms such as severe headache and visual disturbances are more prominent in patients with HELLP syndrome. In terms of laboratory findings, AFL can be differentiated from HELLP syndrome by the presence of leucocytosis, hypoglycaemia, more pronounced hyperbilirubinemia, an initial lack of haemolysis and thrombocytopenia < 100 G/l, as well as lower antithrombin levels < 65% and prolonged prothrombin times. While HELLP syndrome has a fluctuating clinical course with rapid exacerbation within hours or transient remissions, AFL rapidly progresses to acute liver failure if the infant is not delivered immediately. The only causal treatment for both diseases is immediate delivery. Expectant management between 24 + 0 and 33 + 6 weeks of gestation is recommended for HELLP syndrome, but only in cases where the mother can be stabilised and there is no evidence of foetal compromise. The maternal mortality rate for HELLP syndrome in developed countries is approximately 1%, while the rate for AFL is 1.8 – 18%. Perinatal mortality rates are 7 – 20% and 15 – 20%, respectively. While data on the long-term impact of AFL on the health of mother and child is still insufficient, HELLP syndrome is associated with an increased risk of developing cardiovascular, metabolic and neurological diseases in later life.

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Phenotype of acute liver failure in inapparent small cell lung cancer

Gastroenterologie a hepatologie ◽

10.14735/amgh2020404 ◽

2020 ◽

Vol 74 (5) ◽

pp. 404-409

Author(s):

Xénia Faktorová ◽

Terézia Staškovanová ◽

Katarína Bilíková ◽

Richard Hokša ◽

Tomáš Tvrdík ◽

...

Keyword(s):

Lung Cancer ◽

Liver Failure ◽

Acute Liver Failure ◽

Small Cell Lung Cancer ◽

Cell Lung Cancer ◽

Primary Tumour ◽

Small Cell ◽

Rapid Progression ◽

Small Cell Lung ◽

Elevated Liver Enzymes

Acute liver failure is defined by the manifestation of liver failure from 7th to 21st day in a previously healthy liver. The most frequent causes are viral hepatitis B, A, E, drug or toxin-induced hepatotoxicity (Amanita phalloides), rarely Wilson’s disease, autoimmune hepatitis, HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome, or vascular causes (Budd-Chiari syndrome, hypoxic hepatitis). We present a 71-year- -old female patient with metabolic syndrome admitted to hospital with cholestasis, progression of weakness, abdominal pain, and breathlessness. Because of suspected pleuropneumonia, the treatment with ceftriaxone/metronidazole was initiated. Due to cholestasis progression and suspicion of drug-induced liver toxicity, the treatment was stopped on 5th day. Imaging methods (ultrasonography, CT, magnetic resonance imaging) found multiple small liver lesions, suspected metastatic involvement, which was not confirmed by positron emission tomography – computed tomography. Due to the rapid progression of the patient’s condition with the onset of icterus, ascites, encephalopathy, a liver biopsy was not done. The patient died on the 17th day of hospitalization. The primary tumour was not detected during her life, and not by pathological section. The diffuse metastasis of small cell lung cancer (SCLC) in the liver was found by histological post mortem examination. The case report suggests high invasiveness of SCLC with a possibility of unusual manifestation in a form of acute hepatic failure.

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Budd-Chiari Syndrome and Acute Liver Failure: An Uncommon Presentation of Acute Myeloid Leukaemia

GE Portuguese Journal of Gastroenterology ◽

10.1159/000507335 ◽

2020 ◽

Vol 28 (1) ◽

pp. 62-66

Author(s):

Ana Rita Gonçalves Costa ◽

Inês Freitas ◽

Joana Raposo ◽

Gustavo Barbosa ◽

Helena P. Miranda ◽

...

Keyword(s):

Risk Factors ◽

Acute Myeloid Leukaemia ◽

Liver Failure ◽

Acute Liver Failure ◽

Myeloid Leukaemia ◽

Rapid Progression ◽

Budd Chiari Syndrome ◽

Uncommon Presentation ◽

Chiari Syndrome ◽

Acute Myeloid

Acute liver failure (ALF) is a rare entity, particularly in the context of Budd-Chiari syndrome (BCS). BCS is an uncommon disorder with multiple risk factors, most commonly myeloproliferative disorders. In BCS, active search and exclusion of underlying malignancy is mandatory, particularly in the context of ALF, as it may contraindicate liver transplantation (LT). We present the case of a healthy 29-year-old male, without known risk factors for liver disease, who presented to the emergency department with abdominal pain, ascites, and jaundice. BCS with consequent severe acute liver injury with rapid progression to ALF was diagnosed. The patient was listed for LT. The study of peripheral blood finally revealed myeloid blasts, and flow cytometry showed a population of blast cells with abnormal immunophenotypic profile (CD33+ and myeloperoxidase, MPO+). The bone marrow biopsy showed morphological and immunophenotypic aspects of acute myeloid leukaemia (AML) FAB M1. This diagnosis was considered a formal contraindication to LT, so the patient was delisted. ALF contraindicated rescue chemotherapy and AML contraindicated LT. The patient died 48 h after ICU admission. The search for underlying neoplasia is mandatory in the context of BCS, moreover with associated ALF, as it may limit lifesaving treatments and interventions to supportive and palliative care.

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