Differential Diagnosis for 84-year-old with Encephalopathy
Single Most Likely Diagnosis
- Drug-induced liver injury (DILI) from newly started medications: The recent introduction of Jardiance (empagliflozin) and metoprolol XL, coupled with elevated liver enzymes (ALT 181, AST 87, ALP 172) and total bilirubin (4.23), suggests a potential drug-induced liver injury. This condition can lead to encephalopathy, especially in the elderly.
Other Likely Diagnoses
- Hepatic decompensation due to underlying liver disease: Although there's no history of alcohol use, other causes of liver disease (e.g., non-alcoholic fatty liver disease, viral hepatitis) could be contributing to the patient's condition, especially given the elevated liver enzymes and bilirubin.
- Septicemia or infection leading to sepsis: Infections can cause both encephalopathy and liver dysfunction in elderly patients, making this a plausible diagnosis.
- Cardiac causes (e.g., heart failure, cardiac arrhythmias): Metoprolol XL, a beta-blocker, could potentially contribute to or exacerbate cardiac issues, which in turn might lead to hepatic congestion and dysfunction, especially if the patient has pre-existing heart disease.
Do Not Miss Diagnoses
- Acute liver failure from other causes (e.g., acetaminophen overdose, viral hepatitis, ischemic hepatitis): These conditions are less likely given the context but would be catastrophic if missed. Acetaminophen toxicity, for example, can occur even at therapeutic doses in susceptible individuals and can lead to severe liver injury.
- Budd-Chiari syndrome or hepatic vein thrombosis: Although rare, these conditions can cause liver dysfunction and encephalopathy and require prompt diagnosis and treatment to prevent fatal outcomes.
- Malignancy (e.g., liver metastases): While less likely, metastatic disease to the liver could explain the liver dysfunction and should be considered, especially if there's a known history of cancer.
Rare Diagnoses
- Wilson's disease: An inherited disorder that leads to copper accumulation in the liver, brain, and other organs. It's rare, especially as a new diagnosis in an 84-year-old, but could potentially present with liver dysfunction and encephalopathy.
- Autoimmune hepatitis: An autoimmune disease that causes the body's immune system to attack liver cells. It's less common and might not be the first consideration in an elderly patient with new-onset liver enzyme elevations but should be kept in mind.
- Alpha-1 antitrypsin deficiency: A genetic disorder that may cause lung disease and liver disease. It's rare and typically presents earlier in life, but late presentations can occur.