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Young woman with dyspnea and upper abdominal pain

      1. Case description

      A 21-year-old woman presented to the emergency department with severe dyspnea, hypotension (83/46 mmHg), tachycardia (152 beats/min) and upper abdominal pain. Her medical history included familial predisposition for pulmonary embolism. Except dull pain in the right upper abdomen, physical examination was unremarkable. D-dimer, NT-proBNP, troponin T, alanine and aspartate transaminases were elevated and ECG showed S1Q3T3 pattern. Emergency ultrasound revealed massive dilatation of the right atrium and ventricle with a floating thrombus in the inferior caval vein and inhomogeneous liver parenchyma. Due to cardiogenic shock and suspected pulmonary embolism, rescue lysis with alteplase and enoxaparin was administered with consecutive amelioration of blood pressure and heart rate. Abdominal computed tomography (CT) and CT angiography of the pulmonary arteries were performed.

      2. Diagnosis

      Acute congestive hepatopathy associated with pulmonary embolism. CT scan revealed bilateral pulmonary embolism. Additionally, massive hepatomegaly with a ‘kissing liver and spleen sign’ (Fig. 1a and b , red arrows) could be detected. The patient was admitted to the ICU and treated with enoxaparin. Liver parenchyma and parameters restored completely and anticoagulation was changed to rivaroxaban without further thrombotic events.
      Fig. 1
      Fig. 1a Abdominal computed tomography (frontal plane) showing massive hepatomegaly with a ‘kissing liver and spleen sign’ (red arrows). Black arrows point toward periportal halos as a sign of hepatic fluid accumulations due to the secondary venous congestion of the hepatic veins. b Abdominal computed tomography (axial plane) with a ‘kissing liver and spleen sign’. The left hepatic lobe abuts the spleen (red arrows). Black arrows point toward periportal halos. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)
      ‘Kissing liver and spleen sign’ indicates severe enlargement of the liver, spleen or both and may occur in pulmonary embolism. Pulmonary embolism represents another cause for severe hepatomegaly and also for acute liver failure due to preliminary acute right heart failure complicating the clinical outcome [
      • Rubenfire M.
      • Bayram M.
      • Hector-Word Z.
      Pulmonary hypertension in the critical care setting: classification, pathophysiology, diagnosis, and management.
      ,
      • Saner F.H.
      • Heuer M.
      • Meyer M.
      • et al.
      When the heart kills the liver: acute liver failure in congestive heart failure.
      ]. A fast diagnostic work-up including laboratory tests and imaging methods as well as appropriate therapy initiation may prevent acute liver failure in pulmonary embolism.

      Conflict of interest

      All authors declare no conflict of interest.

      Funding

      This research received no specific grant from any funding agency.

      References

        • Rubenfire M.
        • Bayram M.
        • Hector-Word Z.
        Pulmonary hypertension in the critical care setting: classification, pathophysiology, diagnosis, and management.
        Crit Care Clin. 2007; 23: 801-834
        • Saner F.H.
        • Heuer M.
        • Meyer M.
        • et al.
        When the heart kills the liver: acute liver failure in congestive heart failure.
        Eur J Med Res. 2009; 14: 541-546