Case Study of Diagnosis and Treatment of Liver Failure

.

A case of Diagnosis and Treatment of Liver failure Case

A male patient, 33 years old, was admitted to the hospital due to "half month of abdominal distension with fatigue.

The patient had abdominal distension without obvious cause half a month ago, with fatigue and anorexia, yellow urine, no vomiting and bloody black stools, no fever and chills, no abdominal pain and diarrhea, no dizziness and headache, no lower extremity edema. 12 Liver and kidney function: albumin 26.9 g / L, alanine aminotransferase 714.3U / L, aspartate aminotransferase 199.6U / L, total bilirubin 222.5μmol / L, direct bilirubin 127.9μmol / L, creatinine 216.2μmol / L .

Alpha-fetoprotein 180.72ng / mL. Prothrombin time 29.3 seconds. Blood ammonia: 26,2μmol / L Hepatitis B surface antigen positive (+), hepatitis B E antigen positive (+), hepatitis B core antibody positive (+).

Hepatitis B DNA 1.4E + 4 IU / ml. Troponin: 8.506 g / mL.

Type B natriuretic peptide: 1507.2 pg / mL. He was given liver protection, lowering enzymes and turning yellow, and entecavir antiviral therapy.

The patient's abdominal distension with fatigue, anorexia, and yellowish yellow urine symptoms worsened.

For further diagnosis and treatment, it is planned to be transferred to our hospital for "slow onset of acute liver failure".

 

History of Liver Failure Patient

The patient has a history of hypertrophic heart disease for more than 10 years and has been taking metoprolol for a long time.

 

Hepatitis B surface antigen was found to be carried for more than 10 years, and no relevant treatment was given.

 

Physical examination: T 37.1 ℃, HR 102 times / min, R 18 times / min, BP 92/51 mmHg consciousness, good spirit, severe yellow staining of the skin and sclera, no liver palm spider nevus, superficial lymph nodes and no obvious swelling Big.

Breath sounds of both lungs were clear, no dry and wet rales were heard.

The heart rhythm was uniform, and no pathological murmur was heard in the auscultation area of ​​each valve.

The abdomen was slightly swollen, without obvious tenderness and rebound pain. The liver and spleen were not reached below the ribs. The liver area was percussive (-).

The gallbladder was not touched, and the Murphy's sign was negative; mobile dullness (-).

There was no edema in both lower extremities, and the physical examination of the nervous system was exceptional.

 

Biochemistry:

Albumin 30.1 g / L ↓

Alanine aminotransferase 292U / L ↑

Aspartate aminotransferase 115U / L ↑

Glutamyl transpeptidase 114U / L ↑

Total bilirubin 411.4μmol / L ↑

Direct bilirubin 272.6μmol / L ↑

Indirect bilirubin 138.8μmol / L ↑

Total bile acid 199.3μmol / L ↑

Creatinine 248.6μmol / L ↑

 

Coagulation function: prothrombin time 26.3 seconds ↑

 

Cardiac troponin I 3.969 μg / L ↑↑

 

Admission diagnosis:

1. Slow and acute liver failure, Viral hepatitis B, Abdominal effusion

2. Hypertrophic non-obstructive cardiomyopathy, Heart function grade Ⅲ

3. Abnormal renal function

4. Chronic cholecystitis

5. Fatty liver

 

Treated with magnesium isoglycyrrhizinate injection, reduced glutathione injection, adenosylmethionine injection, ursodeoxycholic acid capsules to protect liver and lower enzymes, reduce yellowing, alprostadil injection improves microcirculation, entecavir antiviral, and regulates intestinal microecology , Supplemental albumin, diuretic, plasma transfusion and other medical comprehensive treatment.

 

The patient's TnI is elevated, and the cardiology consultation believes that there is no obvious chest tightness and chest pain. TnI is elevated but lower than before.

Considering hypertrophic non-obstructive cardiomyopathy and cardiac insufficiency, it is recommended to diuretic as appropriate, monitor the amount of electrolytes, and dynamically review myocardial enzymes spectral, when conditions permit, can improve the coronary CTA to determine whether there is coronary disease.

 

Artificial liver therapy indicator

The patient has an artificial liver therapy indicator. Due to cardiac insufficiency and low blood pressure, artificial liver plasma exchange was performed at the ICU and hemodynamics were closely monitored. The patient was placed in the right femoral vein and treated with artificial liver three times.

 

2019-06-24 Biochemistry: albumin 32.5 g / L ↓, alanine aminotransferase 61U / L ↑, total bilirubin 198.6μmol / L ↑, direct bilirubin 107.0μmol / L ↑, creatinine 175.1μmol / L ↑;

 

2019-06-24 Coagulation function: prothrombin time 14.8 seconds ↑

 

B-type natriuretic peptide 1508.7pg / mL ↑, cardiac troponin I 0.453 μg / L ↑

 

The trend of changes in total bilirubin and PT during treatment is shown in the figure below:

 

 

2019-06-24 The patient has fever, blood routine + hypersensitivity CRP: white blood cell count 14.63x10 ^ 9 / L, neutrophil 85%, hypersensitivity C-reactive protein <1.3 mg / L.

Procalcitonin 0.55 ng / ml. The femoral vein was removed and the catheter was placed for bacterial culture at the tip of the catheter.

Daptomycin 0.5 g intravenous infusion qd combined with meropenem 0.5 g q12 h anti-infective treatment (adjust the dose according to renal function).

 

Chest CT: atelectasis of the lower lobe of both lungs; pleural effusion on both sides, more progress than  tablets.

New nodules in the upper lobe of both lungs, consider inflammatory nodules. (As shown below)

 

Considering the possibility of pulmonary fungal infection, add caspofungin needle 35 mg intravenously qd (adjust the dose according to renal function, the first dose of 70 mg).

 

The patient still has fever, abdominal distension, no abdominal pain, no cough and sputum, no urinary urgency and dysuria. Reexamination of liver function suggests that bilirubin is progressively elevated.

 

 Biochemistry: albumin 32.4 g / L ↓, aspartate aminotransferase 58U / L ↑, total bilirubin 437.6μmol / L ↑, direct bilirubin 329.7μmol / L ↑, indirect bilirubin 107.9μmol / L ↑, creatinine 224.6μmol / L ↑

 

Blood routine + hypersensitive CRP: white blood cell count 16.55x10 ^ 9 / L ↑, neutrophil classification 83.7% ↑, hypersensitive C-reactive protein 35.5 mg / L ↑

 

Coagulation function: prothrombin time 21.8 seconds ↑, international standardized ratio 2.17 ↑, partial thromboplastin time 47.2 seconds ↑

 

Procalcitonin: 3.14ng / ml ↑

 

Fungal G + GM test: Aspergillus galactomannan 0.22 μg / L, 1-3-β-D glucan 204.60 pg / ml

 

Chest CT: multiple nodules in both lungs, significantly more progress than the previous film 2019-06-26, considering the possibility of inflammatory lesions fungal infection, the inferior lobes of both lungs are not open. Pleural effusion on both sides, similar to the previous film . Heart shadow increased.

 

Intravenous infusion

Considering the possibility of aspergillus infection in the lungs of patients, the current anti-infection effect is not good. Since lately, the caspofungin needle was changed to voriconazole tablets 0.1 g q12 h to cover Aspergillus, meropenem and daptomycin were discontinued, and the descending step was Piperacillin and tazobactam 4.5 g q8 h intravenous infusion.

 

Bronchoscopy, alveolar lavage fluid Cryptococcus neoformans capsular antigen negative, smear showing a large number of Candida spores, alveolar lavage fluid culture: Aspergillus fumigatus.

 

After the adjustment of the anti-infection regimen, the patient's body temperature gradually became normal, and the reexamination of white blood cells, inflammation indicators, liver and kidney function gradually improved. According to the patient's renal function and voriconazole blood concentration, the dosage of voriconazole tablets was adjusted to 0.2 g q12 h.

 

Biochemistry: aspartate aminotransferase 76U / L ↑, glutamyl transpeptidase 253U / L ↑, total bilirubin 96.1μmol / L ↑, direct bilirubin 41.2μmol / L ↑, indirect bilirubin 54.9 μmol / L ↑, creatinine 95.7μmol / L, glomerular filtration rate-china 84.86 ml / (min · 1.73m ^ 2)

Coagulation function: prothrombin time 14.6 seconds ↑, international standardized ratio 1.37 ↑, gets better and discharged.

Patients with liver failure are prone to various infections due to secondary immunodeficiency, especially the incidence of fungal infections has increased year by year, leading to rapid deterioration of the patient's condition. High-risk factors for liver failure combined with fungal infections include the use of antibacterial drugs and hormones, invasive procedures, and leukopenia.

Fungal infections are most common in lung infections, followed by the digestive tract, urinary tract, blood and abdominal cavity.

The most common pathogens include Candida and Aspergillus. The clinical manifestations of fungal infections lack specificity, are easily covered up by primary symptoms, and are often accompanied by bacterial infections, making early diagnosis difficult.

 

Liver failure was accompanied with renal insufficiency and cardiac insufficiency

In this patient, liver failure was accompanied by renal insufficiency and cardiac insufficiency. After artificial liver treatment, his condition improved for a while, but he was complicated by pulmonary aspergillus infection, which caused liver and kidney function to deteriorate again.

Echinocandins, such as caspofungin, have small liver and kidney side effects and high safety, and are often used as the first choice for end-stage liver disease combined with fungal infections.

In this case, the patient showed no signs of improvement after applying caspofungin. According to the 2016 edition of the Aspergillus Diagnosis and Treatment Guidelines, echinocandin is not recommended as a routine monotherapy for invasive pulmonary aspergillosis.

Although triazole drugs have certain liver and kidney toxicity, experience has shown that regular doses of voriconazole have no significant side effects on the liver. After the patient also switched to voriconazole, the lung infection was controlled and liver and kidney functions were gradually restored.

 

Author's Bio

Name: Gwynneth May

Educational Qualification: MBBS, M.D. (Medicine) Gold Medalist

Profession: Doctor

Experience: 16 Years of Work Experience as a Medical Practitioner

About Me