Cholestasis of Sepsis: A Case Report

Abstract

A 46-year-old man presented with fever, general lethargy, and weight loss over the last few months. He started to develop jaundice and his condition worsened. Blood tests confirmed rising levels of conjugated bilirubin with near-normal alanine aminotransferase, alkaline phosphatase, and prothrombin time. Imaging of the liver and biliary system, including ultrasound, computed tomography (CT), and magnetic resonance cholangiopancreatography (MRCP), did not show any focal lesion or biliary obstruction. Human immunodeficiency virus (HIV) and hepatitis screening were negative. A chest x-ray showed no consolidation. An echocardiogram showed no evidence of endocarditis. An ultrasound of the neck and axilla did not show any enlarged lymph nodes. A chest CT scan revealed a mediastinal abscess that contained acid-fast bacilli when aspirated and stained. The patient was started on first-line antituberculous treatment. The jaundice was thought to be secondary to cholestasis of sepsis and resolved completely over the subsequent weeks. His bilirubin levels returned to normal after treatment initiation.

Pathophysiology of sepsis‐induced cholestasis: A review

“…58 Sepsis may damage sinusoidal perfusion, leading to cholestasis with consequent accumulation of organic anions. 59 Various combinations of changes in liver enzymes and histology are reported to occur in sepsis‐induced cholestasis: (i) high conjugated bilirubin and almost normal ALT, ALP, and prothrombin time 60 ; (ii) increase in total bilirubin, GGT, and ALP, with normal ALT and INR 61 ; (iii) high total bilirubin and ALP with near‐normal ALT and AST 62 ; (iv) liver histological changes and reactive intrahepatic cholestasis. 63 , 64 …”

Acute Sepsis-Induced Cholestatic Disease Presenting With Isolated Hyper-Bilirubinemia

“…Alterations in the production, transport, and excretion of bile secondary to sepsis can precipitate cholestatic liver disease [ 3 ]. An observational prospective study of 608 patients with sepsis found that only 10.9% were diagnosed with sepsis-associated cholestasis, while 89.1% had sepsis without cholestasis [ 4 ].…”

“…Furthermore, one study found cholestasis was present in 33% of patients with septic shock who had been admitted to an intensive care unit [ 5 ]. Sepsis-related cholestasis often presents with jaundice alongside conjugated hyperbilirubinemia with normal or mildly elevated liver enzymes and alkaline phosphatase (ALP) [ 3 ]. Improvements in jaundice and abnormal lab values often occur alongside sepsis resolution, supporting the notion that these two conditions transpire concurrently.…”