Takotsubo Cardiomyopathy Shocking the Liver!

Introduction: Liver transaminases in the thousands may be caused by a few distinct etiologies, including acetaminophen toxicity, viral hepatitis, autoimmune hepatitis and ischemic hepatitis (IH). Lack of systemic or portal blood flow may lead to IH in various situations, including cardiac insufficiency, sepsis, hypovolemia, or portal/hepatic vein thrombosis. Case Description/Methods: An 81-year-old woman with hypertension, breast cancer s/p lumpectomy, and stage IV cholangiocarcinoma (unresectable due to hepatic vein involvement), with recent biliary stent placement and initiation of ivosidenib, presented to the ED with chest pain. Admitting diagnosis was Takotsubo cardiomyopathy (TC) based on classic echocardiographic findings. Gastroenterology was consulted for acutely elevated liver enzymes; AST 4152 U/L, ALT 1260 U/L, ALP 590 U/L the upper limit of normal, and direct bilirubin 3.4 mg/dl. On exam, she was afebrile, hypotensive (BP 83/61), HR 73, alert and oriented, with mild scleral and sublingual icterus. Her abdomen was soft, non-tender, distended. Blood work revealed lactic acid was 11.6 mmol/L, which decreased to 2.6 mmol/L the next day. Acetaminophen level was normal and evaluation for viral hepatitis was negative. Urinalysis, blood cultures and chest x-ray were unremarkable. Ultrasound duplex was negative for biliary obstruction and portal vein thrombosis. The patient's blood pressure was optimized with judicious intravenous hydration. AST and ALT declined rapidly, with lagging of direct bilirubin and ALP which normalized prior to discharge. Discussion: We describe a case of Takotsubo cardiomyopathy leading to acute liver injury due to ischemic hepatitis. There is only one prior report of a similar scenario published in the ACG Case Reports Journal in 2020, which described a woman who developed acute liver failure due to Takotsubo cardiomyopathy. That patient had developed altered mental status due to hepatic encephalopathy, and an elevated INR in addition to liver injury from ischemic hepatitis. Our patient thankfully did not progress to acute liver failure.