Case of the month : Treat the patient and not an Investigation report

One day a 39 year old female Mrs Toaiba (name changed) presented to our clinic at King Fahad Medical City, Riyadh with a history of progressive painless jaundice of 2 weeks duration without any viral prodrome or offending drug intake. The lady was accompanied by her husband and two small kids.

Anxiously her husband pulled out the referral report and showed to me.

While reading it, my jaw fell in shock,as the report read , metastatic liver disease for further evaluation.

The lady was very modest wearing a long Abaya and only her eyes were visible which were reflecting golden yellow color of Jaundice , the tell tale of her ailing Liver. The sweat family appeared very anxious as they had been told by the local doctors regarding the poor prognosis of the disease.

“Daktoor(Doctor)! Please do something to help her , I am worried ” said her anxious husband in a very low tune .

She was his only wife. I don’t think out of place to mention that polygamy in Saudi Arabia is not as common as is perceived outside Saudi Arabia.

ibrahim! it is a headache ,one gets sandwiched between the two demanding ladies , one of the consultants narrated his sad story to me after he had divorced his second wife.

Anyway , Mrs Toiaba was admitted under Dr Khalid Al Sayari and the hunt for the primary tumor was started very next day like a predator in a deep jungle searches for its prey .

An abdominal CT scan showed diffuse enlargement of the liver with multiple hypodense lesions in both lobes of liver. Tumor markers CA 19-9 levels were elevated ,leaving no doubt about her cancer .

All investigations done to search the primary in a metastatic liver disease failed to provide any clue to the primary tumor and the treating team seemed to have lost in woods.

One day as we were going for our morning rounds to 3rd floor of the Main hospital KFMC , her husband seemed to have just come out of the room where his beloved was struggling with liver disease , and was wiping his tears near the gate of the room.

We hurriedly entered the room along with the staff nurse ,and were shocked to see the behavior of Mrs Toiba . The cruel illness had taken off her modesty and she was no more covering her face quite irritable , talking irrelevant.

She was immediately shifted to ICU where she was managed as acute liver failure.

Fortunately she improved

Ibrahim! we should go ahead with a Liver biopsy , said Dr Khalid Al Sayari and liver biopsy was planned to know the primary cancer .

Liver biopsy in the setting of coagulopathy is really challenging.

Myriad of thoughts were racing in our minds .

What are we chasing in a metastatic liver disease ? where prognosis is grim and will she survive with recent onset liver failure ?

That afternoon , we sat with her husband and carefully explained him what all was going on in detail and need for Transjugular Liver biopsy as she had coagulopathy hence conventional biopsy was unsafe.

“Daktoor ! I trust in God and then in all of you , do whatever is good for her” he said while signing the high risk consent for Transjugular liver biopsy and he burst into tears.

Our interventional Radiologist carefully did the Transjugular liver biopsy after transfusion of 4 units of fresh frozen plasma.

I must confess had her husband not consented for the liver biopsy we might have not stressed upon her husband the procedure , keeping in view the poor outcome in a setting of Metastatic liver disease .

The patient remained fine after the procedure and had no complications.

Next day we all went to the well equipped Pathology dept of Main hospital straight away before our routine morning rounds in the 3rd floor .Dr Musa A Faggeeh , the canadian trained histopathologist while minutely focussing on his microscope went on showing the findings of Liver histology to all of us on the magnificent plasma screen in the department.

Look ! the liver biopsy shows extensive hepatocellular necrosis with cholestasis.

There is no evidence of granuloma or malignancy. He went on .

Keeping in mind hypergammaglobulinemia and the absence of malignancy, autoimmune hepatitis should be considered as a diagnosis of exclusion. He confidently concluded.

Generally Saudi nationals struggle while speaking in the english language but a few years of fellowship in the Western countries , which they get soon after MBBS or MD , makes them fluent and invariably their outlook broadens .

She was started on prednisolone (40 mg tablets) once daily. Liver cell function tests were monitored. She showed progressive improvement in her liver cell functions and her coagulation parameters improved over a period of 6 weeks. Repeat ultrasound examination after a period of 9 months showed a normal hepatobiliary system and clearance of previous lesions.

Two years later , as I had moved to Taif University one day I got a phone call from Dr Khalid Al Sayari.

Ibrahim ! Mrs Toaiba has come to the clinic .She has happily delivered her third child , her husband wants to talk to you .It was a great pleasure talking to the valentine of Mrs Toaiba…. great old days !!