Kirk Kerkorian School of Medicine at UNLV Las Vegas, NV
Katerina Roma, DO1, John Rovig, MD1, Salman Mohammed, 1, Jacob Villarama, 1, Justin Jeffries, MD1, Robert G. Gish, MD2, Jeremy Kilburn, MD1 1Kirk Kerkorian School of Medicine at UNLV, Las Vegas, NV; 2Loma Linda School of Medicine, Loma Linda, CA
Introduction: The use of herbal and dietary supplements has increased occurrences of drug-induced liver failure. Acute liver failure (ALF) can rapidly progress to multiorgan failure with about 50% of patients requiring a liver transplant. About 10% of all ALF cases have been due to drug injury while only about 2% have been due to Wilson disease (WD). This article provides a detailed case review of ALF due to the use of alkaline water that was originally thought to be due to WD.
Case Description/Methods: A 35-year-old male with no known past medical history is brought into the emergency department (ED) with altered mental status for the past 2 to 3 weeks. The patient was found to be in acute renal failure and ALF. Computed tomography (CT) of the head was unremarkable and a CT of the abdomen showed hepatomegaly and hepatic steatosis without evidence of cirrhosis. Abdominal ultrasound was negative for portal vein thrombus, and laboratory findings were significant for reduced ceruloplasmin. Due to the absence of other causes for his ALF, the patient's presentation was thought to be due to WD. An ophthalmologist conducted a slit-lamp exam, which was negative for Kayser-Fleischer rings. A liver biopsy showed focal liver cholestasis, bile ductular reaction, and mixed portal inflammation suggestive of drug-induced liver injury. Examination of the liver core biopsies displayed acute and chronic periportal inflammatory infiltrate with eosinophils. The patient’s acute encephalopathy completely resolved after six days, and the patient subsequently reported drinking an alkaline water daily 10-days before the onset of symptoms. After ten days, the patient was transferred to a transplant center, however, with improving liver function and resolution of symptoms, the patient was discharged home without the need for further treatment.
Discussion: Due to increased consumption of herbal and dietary supplements in the United States, the rates of drug-induced liver failure have increased. Many cases of drug-induced liver failure due to these sources are underreported and when they are discovered have been linked to increased rates of liver transplant. This case not only highlights drug-induced acute liver failure and its complicated presentation, but also brings into consideration alkaline water as a potential source for ALF. Cases such as this demonstrate that a thorough history and further understanding of herbal and dietary supplements cannot be overlooked when attempting to elucidate a source in instances of ALF.
Figure: Figure 1. Computed tomography of the head and abdomen. (a) Axial view of head. No abnormalities in the basal ganglia. (b) Coronal view of abdomen.
Variable (normal range)
Two days before admission
Day of admission
Five days after admission
Ten days after admission
Two days after transfer
White Blood Cell k/mm3 (3.10-10.20)
11.13
26.27
14.75
12.20
13.17
Hemoglobin g/dL (13.1-16.8)
14.9
16.3
11.0
9.2
8.9
Platelet k/mm3 (119-332)
314
354
182
163
274
Lactic Acid mmol/L (0.50-1.90)
> 11.70
1.08
1.39
BUN mg/dL (5-26)
9
18
102
30
38
Creatinine mg/dL (0.55-1.30)
0.81
2.11
11.11
1.97
2.0
Bilirubin, Total mg/dL (0.0-1.2)
0.5
2.1
5.0
1.7
1.3
Bilirubin, Direct mg/dL (< = 0.5)
1.6
2.9
1.1
AST U/L (8-34)
40
11,867
193
90
65
ALT U/L (10-49)
< 7
1,001
171
394
289
Alk-Phos U/L (46-116)
89
152
135
165
126
INR (0.80-1.2)
5.37
1.19
0.95
1.0
Prothrombin time (9.3-12.4 seconds)
53
12.6
10.2
11.8
Ceruloplasmin mg/dL (16.0-31.0)
8.7
13.5
24.6
Copper ug/dL (72-166)
52
82
76
Urine Copper Level ug/L
2787
Urine Copper mcg/24hrs (9-71)
40
Alk-Phos (IU/L) to total bilirubin (mg/dL) ratio
72.38
Table: Table 1. Laboratory test results of the patient a day before admission, on the day of admission, five days after admission, ten days after admission, and two days after transfer to an outside facility. AST, aspartate transaminase; ALT, alanine transaminase; Alk-Phos, alkaline phosphatase; INR, International Normalization Ratio; aPTT, activated partial thromboplastin
Disclosures:
Katerina Roma indicated no relevant financial relationships.
John Rovig indicated no relevant financial relationships.
Salman Mohammed indicated no relevant financial relationships.
Jacob Villarama indicated no relevant financial relationships.
Justin Jeffries indicated no relevant financial relationships.
Robert Gish indicated no relevant financial relationships.
Jeremy Kilburn indicated no relevant financial relationships.
Katerina Roma, DO1, John Rovig, MD1, Salman Mohammed, 1, Jacob Villarama, 1, Justin Jeffries, MD1, Robert G. Gish, MD2, Jeremy Kilburn, MD1. B0584 - Drug-Induced Liver Failure Masquerading as Late Onset Wilson Disease: A Case Report, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.
