Case Report
Copyright ©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Hepatol. Nov 27, 2022; 14(11): 1977-1984
Published online Nov 27, 2022. doi: 10.4254/wjh.v14.i11.1977
Multiple hepatic infarctions secondary to diabetic ketoacidosis: A case report
Vitoria Mikaelly da Silva Gomes, Gustavo de Sousa Arantes Ferreira, Luise Cristina Torres Rubim de Barros, Barbara Moreira Ribeiro Trindade dos Santos, Lorenna Paulinelli Bahia Vieira
Vitoria Mikaelly da Silva Gomes, Luise Cristina Torres Rubim de Barros, Barbara Moreira Ribeiro Trindade dos Santos, Lorenna Paulinelli Bahia Vieira, Department of General Surgery, Hospital das Clinicas da Universidade Federal de Minas Gerais, Belo Horizonte 30130100, Minas Gerais, Brazil
Gustavo de Sousa Arantes Ferreira, Liver Transplantation, Instituto de Cardiologia do Distrito Federal, Brasilia 70673900, Distrito Federal, Brazil
Gustavo de Sousa Arantes Ferreira, Lorenna Paulinelli Bahia Vieira, Department of General Surgery, Hospital Metropolitano Doutor Celio de Castro, Belo Horizonte 30620090, Minas Gerais, Brazil
Author contributions: Barros LCTR and Santos BMRT designed the report; Gomes VMS and Ferreira GSA collected the patient’s clinical data, analyzed the data and wrote the paper; Barros LCTR, Santos BMRT and Vieira LPB reviewed the paper.
Informed consent statement: Consent was obtained from the patient, and the signed Informed Consent Form was provided to the publisher.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
CARE Checklist (2016) statement: The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Gustavo de Sousa Arantes Ferreira, MD, MSc, Surgeon, Teacher, Liver Transplantation, Instituto de Cardiologia do Distrito Federal, Setor Sudoeste, S/N, Brasilia 70673900, Distrito Federal, Brazil. gustferr@ufmg.br
Received: May 21, 2022
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
Processing time: 186 Days and 17.2 Hours
Abstract
BACKGROUND

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.

CASE SUMMARY

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.

CONCLUSION

This case highlights that diabetic ketoacidosis can cause non-occlusive HI, possibly presenting as nodular lesions indistinguishable from neoplasms.

Keywords: Hepatic infarction; Non-occlusive infarcts; Diabetic ketoacidosis; Pseudotumor of the liver; Liver infarcts; Case report

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.