DIAGNOSTIC UNCERTAINTY OF A CASE OF FULMINANT HEPATIC FAILURE

Hello everyone this is second year internal  medicine resident , here to discuss a challenging case , me and my team has faced in recent past .

 

 A 18 year old male,from miryalaguda,who completed his 12 th standard , presented to the casualty with chief complaints of 

• Low backache since  1 week 
• Generalized weakness, and loss of appetite since 1 week 
• Fever since 5 days , subsided on medication(on presentation no fever episode ) 
• Yellowish discolouration of eyes since 3 days ,
• High colored urine since  yesterday morning.

HISTORY OF PRESENT ILLNESS-

Patient was apparently asymptomatic 1 year ago ,then he visited a dentist in view of tooth ache , and later got it removed in view of caries tooth .

Since 6 months patient and his mom noticed gradual loss of weight , loosening of clothes . He also gave  history of polyuria,nocturia,polydypsia since 2 months .

He used to wake up atleast 6-7 times after he was asleep in view of polyuria .

10 days ago, patient attended a marraige function outside and after 2 days he developed low backache and 2 episodes of vomitings and 3 episodes of loose stools for one day which subsided on its own.

Next day, patient developed fever,intermittent,high grade,subsided with medication. Patient went to RMP and got symptomatic relief . 

He had loss of appetite and nausea and low back ache .

After 2 days he noticed yellowish discoloration of eyes , so they consulted a doctor and got tests done there  ,which showed elevated total bilirubin , and his sugars were around 360 mg/dl . He was stated on OHA by one of the RMP and he used it for 3 days . But later as his yellowish discoloration of eyes was increasing they came here for further treatment .

He was even complaining of high colored urine since one day. 

PAST HISTORY-

No history of diabetes,asthma,TB ,epilepsy

No history of similar episodes in the past.

History of febrile sezires at 9 months of age .

PERSONAL HISTORY-

Diet-mixed

Appetite-lost

Bowel and bladder-regular

Sleep-adequate

FAMILY HISTORY-

No relevant family history

GENERAL EXAMINATION-

Patient is conscious,coherent and cooperative

VITALS-

Temp-100.5F

BP-110/70 mm Hg

PR-94 BPM ,regular ,normal volume 

RR-24 cycles/min

 Pallor- absent

Icterus-present

Cyanosis-absent

Lymphadenopathy-absent

Clubbing-absent

Oedema-absent

SYSTEMIC EXAMINATION

CVS- S1,S2 heard

No murmurs 

No thrills

RESPIRATORY-

Bilateral air entry present with normal vesicular breath sounds,no wheeze,no dyspnea ,position of trachea is central.

ABDOMEN-

Shape-scaphoid

Tenderness in right hypochondrium,epigastrium

No palpable mass, free fluid,no bruit

Liver and spleen- not palpable

Bowel sounds-present .

On presentation to casualty pt was conscious and able to give his own history ,but was very weak and gave history of low back ache and loss of appetite and nausea.  Temp on admission was 100.5 F. 

His sugars on admission was 283 mg/dl  , we have sent for urine for ketones and abg which was showing metabolic acidosis and ketones were postive . 

 

PROVISIONAL DIAGNOSIS-

?Acute viral hepatitis .

Denovo DM type 1

DKA

This was our Intial provisional diagnosis According to history and examination .

Only total bilirubin (direct and indirect) was done outside ,and enzymes were not done .

INVESTIGATIONS-

Update on day 5-

Subjectively-c/o lethargy from today afternoon. Did not pass urine the entire day.

Objectively- pt is drowsy not responding to verbal commands, responding to painful stimulus , giving bizarre starey looks occasionally.

BP-110/70

PR-70bpm regular normal volume

Abdomen- Palpable bladder

Assessment- ? Absence seizure / ? Intra parenchymal bleed

Plan-sr electrolytes sent

CT brain planned now

Update on day 6-

Acute liver failure with ?acute pancreatic failure

?Hepatic encephalopathy 

Indirect hyperbilirubinemia-? Criggler najjar syndrome

?hepatic coagulopathy

?porphyria

Diabetic ketoacidosis (resolved)

?denovo diabetes type 1

Patient became drowsy and not responding to verbal communication since yesterday evening with acute retention of urine,bizarre starey looks, responding to painful stimuli

?absence seizure

Inj. Loraz 2cc given yesterday night

CT brain done- normal

O/E-

GCS-E2 V2 M3

Pupils-B/L RL dilated

BP -130/80 mmHg

PR-70 bpm

Temp- 100F

CVS- S1,S2 heard

RS- BAE 

UPDATE ON DAY 10-

His repeat LFT

TB 14.3

Indirect bilirubin 4.6

DB 9.6

SGOT 190

SGPT 750

ALP 113

TP 6.2

 *Alb 2.5* 

Glb 3.7

A/G 0.6

Serum ammonia :108 (Normal range)

Urine for porphobilinogen negative

Yesterday night he had one more episode of ?absence seizure where he had loss of awareness of surroundings with staring look and repeating a single word for about 15mins

**covid antibodies positive