A 73-year-old woman with a moderate allergic reaction to beta-lactams and no toxic habits and pathological history of type 2 diabetes mellitus of 30 years duration, hypertension, complete arrhythmia due to atrial fibrillation, moderate osteoobstructive aortic valve disease.
In usual treatment with acenocoumarol, bisoprolol, torasemide, digoxin, escitalopram, lormetazepam, terbutaline, thiotropium bromide, metformin and
The patient was taking metformin at a dose of 850mg 3 times a day, which had been added to her usual treatment 2 weeks before the onset of symptoms.
He came to the emergency room of our hospital because of asthenia, anorexia, dyspnea, polyuria, polydipsia and pain in the right hypochondrium for 15 days.
In the last hours his general condition had worsened and alimentary vomits were added, without alteration of the depositional rhythm or fever.
She had not presented jaundice, choluria, acholia, pruritus or external bleeding.
Epidemiological data of interest were not collected, nor had recently traveled, and denied the use of herbal products or other possible substances.
On physical examination the patient was normal and had normal skin color.
Cardiac auscultation revealed fever 50 beats per minute and pulmonary auscultation was normal.
Abdominal palpation was painful in the right hypochondrium, with no masses or visceromegaly or signs of peritoneal irritation.
The lower extremities showed no edema, signs of deep venous thrombosis or chronic venous insufficiency.
An increase in aminotransferases with glutamic-pyruvic transaminase levels (1,294; creatinine: 260; urea/N: 0,260; bilirubin: 1,450) was found in the laboratory;
The hemogram showed anemia (Hb: 10.3g/dl; Hto: 30.9%, and MCV: 88.7fl), leukocytosis with neutrophilia (23,400 leukocytes/mm3 [91%) and thrombocytopenia (1063mm).
In the coagulation study, prothrombin activity was 9%, INR: 7.43 and activated partial thromboplastin time: 4 episodes (N: 23-37).
Blood gas analysis revealed lactic acidosis with Ph: 7.13, pO2: 70mmHg, pCO2: 36mmHg, bicarbonate: 12mmol/l, and lactate: 6.9mmol/l (N: 0.52).
The patient required admission to the ICU, where transfusion of fresh frozen plasma was required in addition to administration of prothrombin complex and vitamin K to improve coagulation and subsequent transfusion of anemia concentrates.
Platelet count decreased to 30,000/mm3, indirect Coombs test was negative and haptoglobin was normal.
Renal failure was also ruled out due to the development of maximum creatinine levels 3.9mg/dl and 1.46g/dl with good lactic acidosis (maximum clinical and laboratory response, 12.8).
Numerous complementary tests were performed to guide the origin of liver failure.
The serum levels of acetaminophen negative virus (TSV), herpes simplex virus (VHA), hepatitis B virus (HBV), hepatitis B virus (HCV), hepatitis C virus (HCV) were undetectable.
The autoantibodies ANA, AMA, ASMA and ANCA were negative.
Iron metabolism was altered due to transfusions received, but in subsequent controls it was normal.
Ceruloplasmin, copper and alpha-fetoprotein were also normal.
Abdominal ultrasound showed little free intraperitoneal fluid between loops and small bilateral pleural effusion, and chest X-ray showed signs of heart failure.
Abdominal CT revealed two signs of pancreatitis with peripancreatic pigment and a small amount of free intraperitoneal fluid, without peripancreatic necrosis or necrosis images defined.
However, amylasemia, amilasuria and lipase levels were repeatedly normal.
Urocultive and hemocultive tests were requested, which were negative.
During admission to the ICU, the patient had maximum elevations of PTG of 4,506U/l and AST91U/U/l, and in all cases the GGT and alkaline phosphatase were normal.
Coagulation was normalized and treatment with acenocoumarol was temporarily suspended.
Liver biopsy was not considered indicated due to the good evolution.
10 days after admission, TOG values were 40U/l and TPG 276U/l.
She was admitted to the Internal Medicine Department to continue treating her heart and kidney failure and controlling her diabetes.
The urea and creatinine levels at discharge were normal, and the aminotransferases values were in normal range (GOT: 17U/l and GPT: 34U/l).
She was sent home on treatment with insulin glargine and repaglinide with good glycemic control and anticoagulation was resumed with acenocoumarol with good tolerance.
