S5382 Acute Liver Failure in the Setting of a Pyogenic Hepatic Abscess: A Rare and Life-Threatening Presentation

Introduction: Acute liver failure (ALF) is the development of encephalopathy with impaired hepatic function, defined as international normalized ratio (INR) >1.5, in patients without prior liver disease. The leading causes of ALF in the United States include acetaminophen toxicity and viral hepatitis. Ischemic events also trigger ALF due to diminished blood flow. ALF resulting from sepsis is a well-documented phenomenon, as is the development of sepsis secondary to an abscess. However, the onset of ALF solely in the setting of liver abscess without confounding factors or sepsis has not been previously reported. This case report explores this atypical ALF presentation in a patient with a pyogenic liver abscess. Case Description/Methods: A 71-year-old man with no prior liver history was admitted for abdominal pain. He was initially hemodynamically stable (HDS), with blood work revealing mildly elevated transaminases without hyperbilirubinemia or leukocytosis. He started piperacillin-tazobactam with improvement. He then developed lethargy with an INR 1.6, white blood cell count 27, total bilirubin (TBIL) 25.8, and lactate 8. Computed tomography of the abdomen and pelvis then showed “thrombosis of the left portal vein resulting in a left hepatic lobe infarct and suspected necrosis/developing abscess.” He was started on lactulose, then transferred to a tertiary hospital Intensive Care Unit for ALF management. Screening liver disease work-up was negative. He then experienced a pulseless electrical activity event, started dialysis for acute renal failure, and began pressors. TBIL peaked at 52. Patient underwent a liver biopsy which revealed neutrophilic cholangitis with cholestasis and hepatocellular dropout. Over the next 6 weeks, patient had a liver drain placed and long-term antibiotics with gradual improvement. There was never bacterial growth on the blood or abscess cultures, though patient underwent many courses of antibiotics prior to source control. Discussion: ALF with infection typically presents after ischemic events such as septic shock. Although shock liver was a complication encountered during this hospital stay, initial liver injury occurred prior to the cardiac arrest with biopsies pointing towards an infectious phenomenon. Given the unusual development of ALF prior to hemodynamic instability and the subsequent challenging hospitalization, this case not only highlights the importance of a thorough investigation, but emphasizes early imaging, history taking, and source management.