Published online Nov 27, 2022. doi: 10.4254/wjh.v14.i11.1977
Peer-review started: May 21, 2022
First decision: July 25, 2022
Revised: August 8, 2022
Accepted: October 27, 2022
Article in press: October 27, 2022
Published online: November 27, 2022
Hepatic infarctions (HI) are ischemic events of the liver in which a disruption in the blood flow to the hepatocytes leads to focal ischemia and necrosis. Most HI are due to occlusive events in the liver’s blood vessels, but non-occlusive HI may occur. They are associated with disruption of microvasculature, such as in diabetic ketoacidosis. While HI usually presents as peripheral lesions with clear borders, irregular nodular lesions may occur, indistinguishable from liver neoplasms and presenting a diagnostic challenge.
We report a case of multiple extensive HI in a patient with poorly controlled diabetes mellitus, who first presented to the emergency room with diabetic ketoacidosis. He then developed jaundice, thrombocytopenia, and a marked elevation of serum aminotransferases. An ultrasound of the liver showed the presence of multiple irregular lesions. Further investigation with a computerized tomography scan confirmed the presence of multiple hypoattenuating nodules with irregular borders and heterogeneous appearance. These lesions were considered highly suggestive of a primary neoplasm of the liver. While the patient was clinically stable, his bilirubin levels remained persistently elevated, and he underwent an ultrasound-guided percutaneous biopsy of the largest lesion. Biopsy results revealed extensive ischemic necrosis of hepatocytes, with no signs of associated malignancy. Three months after the symptoms, the patient showed great improvement in all clinical and laboratory parameters and extensive regression of the lesions on imaging exams.
This case highlights that diabetic ketoacidosis can cause non-occlusive HI, possibly presenting as nodular lesions indistinguishable from neoplasms.
Core Tip: Hepatic infarction (HI) is usually caused by occlusion of the blood vessels supplying the liver. Non-occlusive HI secondary to diabetic ketoacidosis is an exceedingly rare occurrence, with few cases described in the literature. We report a case of HI secondary to diabetic ketoacidosis, whose diagnosis was complicated by the atypical aspect of the infarction areas on the imaging exams. The appearance of multiple irregular and heterogenous nodules was suggestive of metastatic liver neoplasm, and correct diagnosis could only be obtained by biopsy. This case demonstrates a rare cause of HI, and highlights the diagnostic challenges posed by its atypical presentations.