LSU Health Shreveport (Ochsner Health System) Shreveport, LA, United States
Kabir Husain, DO1, Aditya Vyas, MD2, Meher Sindhoora Mavuram, MD3, Sam Abdehou, MD3, James Morris, MD2 1LSU Health Shreveport (Ochsner Health System), Shreveport, LA; 2Louisiana State University Health Sciences Center, Shreveport, LA; 3LSUHSC-Shreveport, Shreveport, LA
Introduction: Cirrhosis is a late state pattern of fibrosis and regenerative nodules due to repeat hepatic injury. It is typically seen in persons with a long-standing history of alcoholic liver disease, chronic hepatitis C, a wide range of auto-immune disorders, NASH, or congestive hepatopathy. Finding the etiology of the cirrhosis is imperative to guide the management. Hepatotoxic agents also need to be considered when other causes cannot be identified. We are presenting a rare case of an adolescent who was found to have cirrhosis with esophageal varices secondary to pegaspargase (Peg ASP) during the course of treatment for T-cell acute lymphoblastic leukemia (T-ALL).
Case Description/Methods: We have a 17-year-old gentleman with T-ALL, currently on chemotherapy, and reported “liver scarring” who presented with symptomatic anemia and near syncope in the setting of melena with a hemoglobin of 6.2 gm/dl (BL 15). EGD was performed and revealed 3 large columns of esophageal varices needing variceal ligation, gastric erosions and mild PHG. US doppler showed liver cirrhosis, portal HTN, cirrhosis related gallbladder wall edema, and ascites. Autoimmune and infectious causes of cirrhosis were negative. MELD-Na score was noted to be 10. Hepatology was consulted and stated that patient would need to be free of Leukemia for 2-5 years before he can be evaluated for a transplant. Patient was subsequently discharged and a follow up EGD appointment was made for variceal containment.
For his T-ALL, our patient received Total Therapy XVII which is a protocol with different agents including vincristine, daunorubicin, peg ASP, cyclophosphamide, mercaptopurine, methotrexate, and others.
Discussion: Cirrhosis is a chronic liver disease which is associated with an increased risk for hepatocellular carcinoma, increased healthcare cost, and a decreased quality of life. Peg ASP is a bacterial enzyme used in the treatment of T-ALL and is known to be directly hepatotoxic which results in hepatic steatosis and dysfunction. Lab abnormalities are usually noted 2-3 weeks after therapy has begun. When this occurs, the inciting agent is held and results in a delay of chemotherapy treatment and liver function often returns to baseline over the course of 2-4 weeks. However, our patient developed cirrhosis and presented in a decompensated state which is associated with a worse prognosis. With our patient being diagnosed at the rare age of 17, he will likely need a transplant at some point in his life however, T-ALL will present a challenge.
Kabir Husain indicated no relevant financial relationships.
Aditya Vyas indicated no relevant financial relationships.
Meher Sindhoora Mavuram indicated no relevant financial relationships.
Sam Abdehou indicated no relevant financial relationships.
James Morris indicated no relevant financial relationships.
Kabir Husain, DO1, Aditya Vyas, MD2, Meher Sindhoora Mavuram, MD3, Sam Abdehou, MD3, James Morris, MD2. P0808 - College-Aged Cirrhosis, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.