Liver Failure Complicating a Febrile Illness in a Middle-Aged Man

Gastroenterology 2016;150:1542–1544 A 53-year-old safety inspector from rural Australia was transferred to a major liver center with liver failure, one week after presentation to another hospital with 10 days of fevers, headache, lethargy and myalgias and a chest x-ray showing right basal consolidative changes. He was treated initially for communityacquired pneumonia with ceftriaxone. Despite an improvement in his respiratory status, his clinic state deteriorated with ongoing fevers and worsening hyperbilirubinemia, coagulopathy and renal impairment requiring hospital transfer and admission to the high dependency unit where his antibiotics were changed to tazobactam and piperacillin. His past history included type 2 diabetes mellitus, hypertension and a chronic alcohol intake of over 400 grams per week. He had no history of recent travel and no close contacts were unwell. His medications were atenolol, amlodipine and valsartan. He was an ex-smoker. He had recently worked in an abattoir (a slaughterhouse) inspecting conditions for the processing of cattle. Blood tests at the time showed a normocytic anaemia with haemoglobin of 98g/L (reference range 130-180g/L), white cell count 12.3x10/L (4.0-11.0x10), neutrophils 10.1x10/L (2-7.5x10), lymphocytes 0.5x10/L (1.0-4.0x10), international normalized ratio 2.2, urea 12.2 mmol/L (3.0-9.2mmol/L), creatinine 114 micromol/L (62 micromol/L to 106 micromol/L), bilirubin 337 micromol/L ( 3200 units). CT of the abdomen showed features consistent with underlying cirrhosis with portal hypertension and small volume ascites, but no lymphadenopathy or mass lesions were seen. He was treated for presumed alcoholic hepatitis with pentoxyfilline for 1 week with no improvement in his clinical state and persistent liver function derangement, with bilrubin rising to 324 micromol/L, ALT 113 units/L and AST 133units/L. A liver biopsy was performed which showed background cirrhosis with a steatohepatitis pattern as well as extensive small granulomas (Figure A) with the appearance of poorly formed rings surrounding a central lipid vacuole (Figure B).