Abstracts S427
passive congestion. Because of the potential for AFLP, the patient underwent
an urgent caesarian section ten hours after her liver biopsy. Her ALT and cre-
atinine improved to 106 IU/L and 0.8 mg/dL respectively, within twelve hours
of delivery. Discussion: The rapid improvement in the patient’s ALT and renal
failure favored a diagnosis of AFLP. However, the patient’s clinical presentation
was atypical for AFLP as she had no evidence of coagulopathy or encephalopa-
thy and she had some improvement after her initial presentation. Although
microvesicular steatosis can be seen in cocaine toxicity, the paucity of other
typical cocaine induced injury on the liver biopsy helped guide treatment. This
case highlights the difficult clinical decision-making when faced with a pos-
sible diagnosis of AFLP and the critical factors that contribute to its manage-
ment. It also illustrates the importance of a multi-disciplinary approach for
care of the pregnant patient with hepatitis.
1056
A Case of Clostridium septicum Liver Abscess Associated with Malignancy
Rani Modayil, MD, Sony Modayil, BS, Zainab Mogul-Ashraf, MD,
James Grendell, MD. Winthrop University Hospital, Mineola, NY.
Purpose: A 53-year-old Caucasian man is brought to the emergency room
after being found unresponsive at his group home. On arrival, he is hypoten-
sive but regains consciousness after fluid resuscitation. He reports noticing
increasing abdominal girth over past week, bloating, lower extremity swelling,
weight loss, decreased appetite, several months of hematochezia and diarrhea.
His medical history is limited to schizophrenia, since he lacks medical follow-
up. On physical examination, he appears jaundiced, cachectic, and uncom-
fortable. His abdomen is soft but distended with significant hepatomegaly and
liver edge extending 7 finger-breaths below the right costal margin. Rectal
exam reveals fullness with brown guaiac positive stool. Other pertinent find-
ings include temporal wasting, sclera icterus, dry mucus membranes, bilateral
crackles and bilateral lower extremity pitting edema. On CT scan, the liver is
enlarged, diffusely heterogeneous with multiple discrete masses. Several areas
of gas and debris are present in the hepatic parenchyma. Rectosigmoid thick-
ening is noted. He is placed on mechanical ventilatory support for hypoxic
respiratory failure from septicemia. Antibiotic therapy with intravenous tige-
cycline and clindamycin is initiated. He underwent CT-guided percutaneous
abscess drainage. The blood and abscess culture reveal Clostridium septicum,
high CEA and Ca19-9 markers. He remained hypotensive requiring multiple
agents for vasopressor support, and became hypothermic and anuric. Fam-
ily withdrew care on the 5th day of hospital stay. Autopsy revealed a primary
rectal adenocarcinoma with liver metastasis. Pyogenic liver abscess has been
described since the time of Hippocrates (400 BC). The incidence of pyogenic
liver abscess is estimated to be 8-15 cases per 100,000 persons. Fatalities can
range from 3 to 30%. The risk factors associated with mortality have included
age, bacteremia, and comorbities such as cirrhosis, renal failure and malig-
nancy. Clostridium septicum is an anaerobic gram-positive spore forming
bacillus. C. septicum sepsis is often fulminant with reported mortality rates of
approximately 60%. A relationship between C. septicum infection and malig-
nancy, especially hematologic or colonic malignancy has been suggested. One
explanation as to why Clostridium infections are present in malignancy is that
anaerobic glycolysis of the tumor provides a hypoxic and acidic environment
that may be conducive to spore germination thus leading to infection. An early
diagnosis is critical in choosing appropriate antibiotic and surgical interven-
tion for treatment of C. septicum related sepsis.
1057
Hepatocellular Carcinoma Causing Severe Leucocytosis: A Rare Paraneo-
plastic Syndrome Masquerading as Liver Abscesses and Carrying a Poor
Prognosis
Toufic Kachaamy, MD, Jason Adam, MD, Kishoor Muniyappa, MD, Puneet Puri,
MD, Richard Sterling, MD. Gastroenterology, VCU-Biology, Richmond, VA.
Purpose: Hepatocellular carcinoma (HCC) has one of the fastest growing
incidences among cancers. As the numbers of HCC diagnoses increases,
new clinical presentations are being identified. Here we are presenting a very
© 2012 by the American College of Gastroenterology
unusual presentation of HCC with a rare paraneoplastic syndrome. A 64-year-
old Caucasian man presented 1 month after hernia repair with right upper
quadrant abdominal pain and 22 pound weight loss, night sweats and low
grade fever. He had a history of multiple soft tissue and bone infections since
childhood raising the possibility of immune deficiency and a granulocyte
defect. He had no history of liver disease or heavy alcohol consumption. He
had no family history of liver disease. On exam, he had few telangiectasia on
the upper chest, muscle wasting and tender hepatomegaly. His labs showed:
white blood cell of 59.9 10e6/mL, hemoglobin 13.8 g/dL, platelet 153 10e6/
mL, AST 61 u/L, ALT 32 u/L, alkaline phosphatase 352 u/L, total bilirubin 0.7
mg/dL, albumin 3.2 g/dL, BUN 17 mg/dL, creatinine 0.86 mg/dL. Lactate 4.8
mmol/L, AFP 12.1 ng/mL. He was initially seen by Hematology and under-
went a bone marrow biopsy which did not show any evidence of leukemia.
His abdominal CAT scan was read as: Heterogeneous ill-defined coalescent
fluid-filled or necrotic regions with multiple septations in the right and left
hepatic lobes concerning for hepatic abscesses. There was associated throm-
bosis of the left, right, and main portal veins as well as the middle hepatic
vein. He was treated with broad spectrum antibiotics for over a week with no
change in his WBC count or symptoms. CT guided FNA showed malignant
cells consistent with HCC. An abdominal MRI showed markedly diminished
signal intensity of the liver indicative of primary hemochromatosis. His ferritin
was 6,140 ng/mL and his transferrin was < 93 mg/dL. Genetic testing showed
him to be homozygous for C282Y. He was discharged home and seen in the
clinic to discuss treatment with Sorafenib. He however expired a week later.
Another patient with a similar presentation died within 3 days of presentation.
Leukomoid reaction defined as a WBC over 50 10e6/mL on presentation of
HCC has been reported in very few cases in the literature. It is likely related to
the production of granulocyte colony stimulating factor (G-CSF) by the tumor
cells as evidenced by increased G-CSF levels in some patients and immunohis-
tochemical staining of HCC cell for G-CSF. It likely represents an aggressive
form of this disease as most reported patients died within days to weeks after
diagnosis. The combination of rapid growth causing liquefactive necrosis with
certain appearance on imaging in addition to leukocytosis cause this disease
entity to mimic a liver abscess.
1058
Acute Liver Failure Secondary to Metastatic Breast Cancer
Varun Takyar, MD,1 Sunitha Musuku, MD,2 Thomas Boyer, MD, FACG2.
1. University of Arizona-South Campus, Tucson, AZ; 2. University of Arizona
Medical Center, Tucson, AZ.
Introduction: 40-60% of patients with breast cancer have liver metastasis at
time of death. Most liver metastases are asymptomatic. However, rarely, patients
can have disseminated intra-sinusoidal metastatic liver disease (DISML) lead-
ing to acute liver failure and death. Case Report: A 57-year-old female pre-
sented to University of Arizona Medical Center with altered mental status. Her
past medical history was significant for a history of infiltrative ductal breast
carcinoma for which she had bilateral mastectomies, chemotherapy and right
breast radiotherapy 4 months prior to admission. Two weeks before the admis-
sion, she was seen in an emergency department for abdominal pain and was
noted to have aspartate aminotransferase (AST) level of 280 IU/dL, alanine
aminotransferase (ALT) level of 162 IU/dL and total bilirubin of 0.8 mg/dL.
Physical examination on admission revealed a comatose patient with jaundice
and ascites. Laboratory studies showed serum creatinine of 2.5 mg/dL, ALT
of 363 IU/dL, AST of 1249 IU/dL, GGT of 665 IU/dL, alkaline phosphatase of
756 IU/dL and total bilirubin was 17.6 mg/dL. The patient was noted to have
platelets of 65 K/μL and INR was 2.7. Serologies for hepatitis A, B and C were
negative with acetaminophen level was less than 3 ug/mL. Doppler ultrasound
revealed hepatomegaly and no evidence of thrombus in the hepatic or portal
veins. MRI showed hepatic steatosis and a normal spleen and pancreas. The
patient’s condition deteriorated with worsening encephalopathy, coagulopathy,
sepsis and hepatorenal syndrome resulting in death 4 days following admis-
sion. At autopsy, there were widespread nodular metastases in the liver. Micro-
scopic examination showed malignant cells plugging the hepatic sinusoids
and small vascular spaces with infiltration of adjacent hepatic parenchyma.
There were no peritoneal metastases. Conclusions: Liver is the most common
The American Journal of GASTROENTEROLOGY