Differential Diagnosis for 74-year-old in Liver Failure
Single Most Likely Diagnosis
- Fulminant Hepatitis B: Given the patient's presentation with acute liver failure (ALF) characterized by coagulopathy (INR 2.5, PT 27.6), rising AST and ALT, and minimal bilirubin elevation, along with serological evidence of hepatitis B infection (HBsAb positive, HBcIgG positive, and pending HBV DNA), this diagnosis is highly plausible. The absence of HBcIgM suggests a chronic infection, but the clinical presentation could indicate a reactivation or superinfection.
Other Likely Diagnoses
- Acute-on-Chronic Liver Failure (ACLF): The patient's cirrhosis on ultrasound and presentation with liver failure could suggest an acute decompensation of chronic liver disease, potentially triggered by a reactivation of hepatitis B or another insult.
- Sepsis: Leukocytosis (WBC 30,000) and rising lactate levels suggest a possible infectious process, which could be contributing to or exacerbating liver failure.
- Ischemic Hepatitis: The rising troponin and lactate could indicate a hypoperfusion state leading to ischemic injury to the liver, although this would typically be seen in the context of shock or severe hypotension, which is not explicitly mentioned.
Do Not Miss Diagnoses
- Hepatic Artery Thrombosis: Although less common, this condition can lead to liver infarction and failure, especially in the setting of cirrhosis. It's crucial to consider, especially if the patient has risk factors for thrombosis.
- Budd-Chiari Syndrome: This condition, characterized by hepatic vein thrombosis, can cause acute liver failure and should be considered, especially if there are risk factors for thrombophilia.
- Wilson's Disease: Although rare, Wilson's disease can cause fulminant liver failure and should be considered in any case of liver failure of unclear etiology, especially in younger patients, but it's less likely given the patient's age and presentation.
Rare Diagnoses
- Hepatitis B Delta Coinfection: This should be considered if the HBV DNA comes back high, as it can exacerbate liver disease. Testing for hepatitis D (delta) is typically reserved for those with evidence of active HBV infection, as delta can only infect in the presence of HBV.
- Autoimmune Hepatitis: Although less likely given the serological markers provided, autoimmune hepatitis can cause acute liver failure and should be considered if other diagnoses are ruled out.
- Drug-induced Liver Injury (DILI): Given the rising liver enzymes, it's essential to consider DILI, especially if the patient has been exposed to new medications or substances known to cause liver injury.
Testing for hepatitis B delta (HDV) should be considered if the HBV DNA comes back high, as co-infection or superinfection with HDV can significantly impact the clinical course and management of the patient. The patient's presentation with fulminant liver failure and the serological evidence of hepatitis B infection make it crucial to investigate further to guide appropriate management and potential listing for liver transplantation if necessary.