Small Cell, Big Liver

Abstract

INTRODUCTION: Small cell lung cancer (SCLC) frequently presents with metastatic disease at the time of diagnosis, but fulminant liver failure is a rare initial presentation. CASE PRESENTATION: A 65 year old initially presented with complaints of fatigue and lower extremity edema. His physical exam showed jaundice, asterexis, hepatomegaly, splenomegaly, and symmetric lower extremity pitting edema. Abnormal liver function tests included: bilirubin 6.03 mg/dL, alkaline phosphatase 439 IU/L, AST 244 IU/L, and ALT 403 IU/L, all of which were normal two months prior. Imaging showed hepatomegaly with multiple solid lesions infiltrating the liver. CT did not show any masses within the GI tract, but a 1.4 cm spiculated pulmonary nodule was discovered. A 65 pack year smoking history made lung cancer with liver metastasis high on the differential. Liver biopsy was performed, and immunohistochemical staining indicated SCLC. The patient was discharged with the plan to start chemotherapy as an outpatient. One week later, the patient was admitted to the hospital for failure to thrive and altered mental status. His liver function testing had deteriorated significantly, with bilirubin increasing to 13.2 mg/dL and worsening transaminitis, coagulopathy, and thrombocytopenia. He was admitted to the intensive care unit and treated for septic shock. Three days after admission, the patient and his family wished to shift the focus of care to comfort measures, and the patient shortly succumbed to his illness. DISCUSSION: Fulminant liver failure is rare and involves acute onset of encephalopathy, coagulopathy, and rapidly deteriorating liver function in individuals without pre-existing liver disease. The majority of cases are due to viral hepatitis, drug toxicities, autoimmune disease, or hypoperfusion1. Fulminant liver failure resulting from diffuse parenchymal infiltration by a metastatic tumor is rare, but when it occurs prognosis is extremely poor. SCLC frequently presents with metastatic disease at the time of diagnosis, but few cases of hepatic failure due to metastasis have been reported. Karia et al. described 21 previously reported cases of fulminant liver failure from SCLC2. The diagnosis was made at autopsy in the majority of cases. Three of the 21 patients described were given chemotherapy despite severe encephalopathy. The patients that received chemotherapy had an impressive improvement in survival and encephalopathy. Due to the rapidity of clinical deterioration, chemotherapy was not administered in our patient. CONCLUSION(S): This case is significant because fulminant liver failure due to metastatic SCLC while rare, if diagnosed early, has shown good responses to chemotherapy with improvement in liver failure, encephalopathy, and survival. A high index of suspicion and tissue sampling are required to make the diagnosis.