Chronic Pericardial Constriction Induced Severe Ischemic Hepatitis Manifesting as Hypoglycemic Attack

Abstract

he correlation between cardiac disease and liver dysfunction is well documented, but constrictive pericarditis (CP) rarely presents with ischemic hepatitis. Case ReportA 57-year-old woman with disturbed consciousness was transported to the emergency room. Her blood pressure was 104/88 mmHg, pulse rate was 98/min with regular rhythm, and she was afebrile. Her jugular vein was distended and showed venous collapse in the diastolic phase. Her legs were considerably edematous. A grade 2/6 systolic regurgitant murmur was audible at the right sternal border in the 4 th intercostal space, but excess heart sounds were unclear. On pulmonary auscultation, sounds were hardly heard in the left lung field. Computed tomography (CT) did not show any evidence of organic lesion in the brain. Though she had no predisposition to hypoglycemia, her serum glucose level was 23 ng/ml and a venous infusion of glucose restored normal consciousness. The first blood gas analysis under 5 L/min oxygen inhaled when just arriving at the hospital showed severe respiratory acidosis (Table 1). However, after recovery of consciousness, the hypercapnia was soon reversed. In addition to low levels of serum glucose, laboratory results showed high necro-inflammatory activity of the liver with an alanine transferase (ALT) level of 1,755 U/L, aspartate transferase (AST) level of 3,615 U/L, lactate dehydrogenase (LDH) level of 5,160 U/L, 47% prothrombin time ratio, and total bilirubin (T-Bil) level of 3.9 mg/dl (Table 1). She was seronegative for both hepatitis B virus (HBV) and hepatitis C virus (HCV), and had not taken any hepatotoxic medicines. Ultrasonography showed no findings of the abdominal organs but there was a small amount of ascetic fluid. Her recent laboratory data and physical (Received October 29, 2007; revised manuscript received March 6, 2008; accepted April 3, 2008; released online November 11, 2008) Department of Cardiovascular Medicine, *Department of Gastroenterology, Nantan General Hospital, Nantan and **Department of Cardiovascular Medicine, Kyoto Prefectural University School of Medicine, Kyoto, Japan Mailing address: Tetsuya Nomura, MD, Department of Cardiovascular Medicine, Nantan General Hospital, 25 Yagi-Ueno, Yagi-cho, Nantan 629-0197, Japan. E-mail: t2-ya@za2.so-net.ne.jp All rights are reserved to the Japanese Circulation Society. For permissions, please e-mail: cj@j-circ.or.jp Chronic Pericardial Constriction Induced Severe Ischemic Hepatitis Manifesting as Hypoglycemic AttackTetsuya Nomura, MD; Natsuya Keira, MD; Yota Urakabe, MD; Daisuke Naito, MD; Mayuka Nakayama, MD; Atsumichi Kido, MD; Hidetoshi Kanemasa, MD*; Hiroaki Matsubara, MD**; Tetsuya Tatsumi, MD Ischemic hepatitis, otherwise known as "shock liver", is characterized by a massive, but transient increase in serum transaminase levels, usually associated with cardiac failure. A patient who did not have a predisposition to hypoglycemia was discovered at home with disturbed consciousness caused by hypoglycemia. She had been diagnosed as having constrictive pericar...

Hypoxic Signaling and Cholesterol Lipotoxicity in Fatty Liver Disease Progression

“…This might be important under acute conditions, such as ischemic hepatitis. Ischemic hepatitis, described as “shock liver,” is characterized by a massive but transient increase in serum transaminase levels, usually associated with cardiac failure and hypoglycemia [ 113 ]. Another physiological situation that might result in glucose production failure is excessive consumption of alcohol during fasting, which can lead to severe hypoglycemia and sudden death [ 114 ] ( Figure 2 ).…”

Hypoglycemia detected during cardiac arrest of a nondiabetic patient with heart failure

“…The most frequent causes are leftand right-sided heart failure, chronic obstructive lung disease, and chronic renal failure. [1,2] During an acute episode, more than 90% of patients have transient deterioration of their renal functions. Hypoglycemia can accompany these findings, and in one report of 34 patients with ischemic hepatitis, hypoglycemia was reported in 11 (32.4%) patients.…”

“…Unexplained hypoglycemia (serum glucose level <20 mg/dl) was the detectable cause in 1 of these arrests. [5] Finally, Nomura et al [2] described an unconscious patient with severe ischemic hepatitis caused by chronic pericardial effusion. In that case, the hypoglycemia was explained by reduced gluconeogenesis in the exhausted liver.…”

Inflammation and Hypoglycemia: The Lipid Connection

“…Patients with ischemic hepatitis and vasopressor therapy have a significantly increased mortality risk in the medical intensive care unit population. Ischemic hepatitis causes several complications including spontaneous hypoglycemia which can be considered secondary to impairment of gluconeogenic response in the exhausted liver (Fuhrmann, V et al, 2010;Fuhrmann, V et al, 2009;Nomura, T et al, 2009). …”