Acute Liver Failure following a Single Dose of Atezolizumab, as Assessed for Causality Using the Updated RUCAM

Abstract

Immune checkpoint inhibitors have become major therapeutic agents in oncology over the last few years. However, they are associated with a variety of potentially severe autoimmune phenomena. We present a patient with advanced adenocarcinoma of the lung, who presented with acute liver injury two weeks following his first treatment with atezolizumab, rapidly deteriorating to fulminant liver failure. A thorough evaluation of infectious, vascular, metabolic, and autoimmune etiologies did not yield any results. Liver pathology was nonspecific. Using RUCAM as a causality assessment method indicated probable connection between atezolizumab and liver damage. To our knowledge, this is the first documented report of a patient developing acute liver failure shortly after immune checkpoint inhibitor initiation.

Figure 1

Liver Doppler sonography showing normal venous flow in the main portal vein (a) and three hepatic veins (b).

Figure 2

Liver biopsy showing centrilobular coagulative necrosis (yellow arrows) with marked sinusoidal dilatation (black arrows). No significant inflammatory infiltrate is seen.