Case Presentation: A 53 years old woman presented to the outside hospital with altered mental status. She was found to have acute liver failure on lab investigations and was transferred to our institution for further work up and management. Patient had significant past medical history of scoliosis, COPD, Bipolar disorder and recent motor vehicle accident (MVA). Patient was involved in a MVA 3 days prior to the admission when she was evaluated in the ER and found to have acute, minimally displaced mid sternal fracture and small splenic laceration. During that admission patient was found to have normal LFTs. She was monitored for about 24 hours in the hospital and discharged home in stable condition.
After 2 days she presented with altered mental status. On arrival to our institution patient was found to be in acute liver failure with INR 1.7, AST 4654 U/L, ALT 3624 U/L, ammonia 69 umol/L. Extensive lab investigations for etiology of liver failure including acetaminophen level (checked twice over the interval of 12 hours), acute hepatitis panel including serologies for hepatitis A, B, C, D and E, HIV Ag/Ab, ANA titer, Anti Sm Ab and Anti Mitochondrial Ab were non-diagnostic. CT scan of Chest/Abdomen/Pelvis with contrast showed sternal fracture with minimal retrosternal hematoma and no acute abdominal pathology and no signs of any blunt injury or laceration of the liver. Patient was also found to have elevated troponin I level which peaked at 2.030 ng/ML. A Trans-thoracic Echocardiogram (TTE) was obtained which showed significant findings of normal LVEF, mild right ventricular dilation, mild to moderately reduced right ventricular function and mild tricuspid regurgitation.
Patient was started on conservative management with IV fluid and lactulose for elevated ammonia level. Over the period of 4 days patient’s clinical condition improved significantly with resolution of altered mental status and normalization of LFTs.
Discussion: We present a rare case of acute liver failure from congestive hepatopathy due to right ventricular dysfunction and tricuspid regurgitation caused by blunt cardiac injury. The reported incidence of cardiac injury following blunt chest wall trauma is in the range of 8% to 76%. There has been no case reported to our knowledge of blunt cardiac injury presenting as acute liver failure.
With anterior chest wall trauma, right ventricle is at the greatest risk of injury because it is the most anterior part of the heart. Injury to the right ventricle or tricuspid valve can lead to reduction in the forward flow which can ultimately lead to elevated RA pressure and subsequently congestive hepatopathy. Diagnosis of the condition requires high degree of clinical suspicion and echocardiography demonstrating right ventricular dysfunction. Management of the condition depends on the severity of the cardiac injury. Patients can be managed conservatively in most cases with mild to moderate injury without severe tricuspid regurgitation or rupture of the valve. However, patients may require valve replacement surgery in severe cases with traumatic tricuspid regurgitation or valve rupture.
Conclusions: Anterior chest wall trauma can lead to blunt cardiac injury which can lead to several complications from either myocardial or valvular injuries. We present a rare case of blunt cardiac injury from sternal fracture leading to acute liver failure. Cardiac evaluation including TTE should be considered as a routine part of evaluation for blunt chest wall trauma.