A Case of medication-induced fatal fulminant liver failure in a woman with hormone-positive breast cancer

Abstract

A 79-year-old female with a past medical history
notable for stage IV breast cancer (ER+, PR+, HER2–
) refractory to standard of care chemotherapy,
diabetes mellitus, hyperlipidemia, and gastric
esophageal reflux disease presented to the hospital
with acute encephalopathy and jaundice. Recently,
she had been started on palbociclib and fulvestrant.
Other home medications included metformin,
atorvastatin, and omeprazole. Clinical examination
revealed confusion, jaundice, and generalized
abdominal pain. Liver injury was evident based on
lab results showing an elevated total bilirubin of 5
mg/dl, aspartate transaminase of 200 u/l, alanine
transaminase of 50 u/l, alkaline phosphatase
of 150 u/l, INR of 3.8, ammonia of 70 u/L, and
platelets of 35 x109/L. Serum cirrhotic studies,
acetaminophen levels, autoimmune serology and
viral hepatitis workup was non-revealing. Roussel
Uclaf Causality Assessment Method (RUCAM)
for palbociclib was 8 (probable) [1,2]. Drug-
Induced Liver Injury Network (DILIN) severity for
palbociclib was 5+ (fatal) [3]. Imaging studies were
obtained but limited to abdominal sonography
due to acute kidney injury that was noted on
admission. Sonography showed a homogenous,
nodular and enlarged liver surrounding extending
inferiorly beyond the right kidney. Gallbladder
sludge was present with borderline but nonspecific
wall thickening. No was an absence of surrounding
fat stranding or pericholecystic fluid. All hepatic
findings compared were compared to abdominal
imaging studies performed two-years prior and
determined to be new and significant. Despite
standard of care therapies and steroids her condition
deteriorated. Aspartate transaminase and total
bilirubin continued to increase beyond levels greater
than 10 times the upper limit of normal representing
worsening liver injury. The patient subsequently
received supportive treatment and was transitioned
to hospice care.