Metastatic melanoma: an unexpected cause of acute liver failure

Abstract

Acute liver failure secondary to metastatic melanoma is exceedingly rare with the literature limited to case reports. The disease itself presents with vague symptoms making diagnosis difficult without a high clinical suspicion. Further to this, the prognosis of acute liver failure secondary to metastatic melanoma is dismal. We present the case of a 59-year-old male with a distant history of previously excised cutaneous melanoma who presented to our institution with abdominal pain and liver enzyme derangement suggestive of acute hepatitis. Due to progressive derangement in liver function and cross-sectional imaging suggestive of an infiltrative cause, a left axillary lymph node was biopsied which demonstrated metastatic melanoma. The patient subsequently deteriorated into acute liver failure and despite acute treatment of his underlying metastatic melanoma died 17 days post initial presentation. This case highlights an uncommon cause of acute liver failure as well as the poor prognosis associated with acute liver failure secondary to metastatic melanoma.

Keywords: Acute liver failure; Hepatitis; Melanoma; Metastatic melanoma.

Fig. 1

A Abdominal ultrasound demonstrating hepatic nodularity; B MRCP demonstrating a diffusely abnormal and heterogenous liver; C FDG-PET/CT scan revealed intensely FDG avid left axillary, peripancreatic and portocaval lymphadenopathy

Fig. 2

A Hematoxylin and eosin staining of left axillary lymph node core biopsy demonstrating discohesive nests of epithelioid cells showing hyperchromatic nuclei and nucleoli. Prominent pigment is present. B Immunohistochemistry (IHC) for MART1 is positive consistent with metastatic melanoma

Fig. 3

Line graph depicting clinical and biochemical deterioration during inpatient admission. ICI – immune checkpoint inhibitor; HRS-1 – hepatorenal syndrome type 1. AST – aspartate aminotransferase; ALT – alanine aminotransferase; Alk. Phos.—alkaline phosphatase; GGT—Gamma Glutamyl Transferase; LDH – Lactate dehydrogenase