A Case of medication-induced fatal fulminant liver failure in a woman with hormone-positive breast cancer

A 79-year-old female with a past medical history notable for stage IV breast cancer (ER+, PR+, HER2-) refractory to standard of care chemotherapy, diabetes mellitus, hyperlipidemia, and gastric esophageal reflux disease presented to the hospital with acute encephalopathy and jaundice. Recently, she had been started on palbociclib and fulvestrant. Other home medications included metformin, atorvastatin, and omeprazole. Clinical examination revealed confusion, jaundice, and generalized abdominal pain. Liver injury was evident based on lab results showing an elevated total bilirubin of 5 mg/dl, aspartate transaminase of 200 u/l, alanine transaminase of 50 u/l, alkaline phosphatase of 150 u/l, INR of 3.8, ammonia of 70 u/L, and platelets of 35 x109/L. Serum cirrhotic studies, acetaminophen levels, autoimmune serology and viral hepatitis workup was non-revealing. Roussel Uclaf Causality Assessment Method (RUCAM) for palbociclib was 8 (probable) Drug-Induced Liver Injury Network (DILIN) severity for palbociclib was 5+ (fatal) Imaging studies were obtained but limited to abdominal sonography due to acute kidney injury that was noted on admission. Sonography showed a homogenous, nodular and enlarged liver surrounding extending inferiorly beyond the right kidney. Gallbladder sludge was present with borderline but nonspecific wall thickening. No was an absence of surrounding fat stranding or pericholecystic fluid. All hepatic