Hypoxic hepatitis : a difficult diagnosis when the cardiomyopathy remains unrecognized and the course of liver enzymes follows an atypical pattern. A report of two cases

In a clinical setting of cardiac or circulatory failure, the diagnosis of hypoxic (ischaemic) hepatitis is easy and can be elicited on mere clinical and biochemical features. We report two cases of hypoxic hepatitis where cardiomyopathy remained unrecognized at admission due to the lack of conventional signs of congestive heart failure and where the increase in liver enzymes activities followed an atypical pattern, characterized by only moderate elevation of serum aminotransferases activities, low ASAT/ALAT ratio and elevated ALAT/LDH ratio. This atypical pattern not suggestive of hypoxic hepatitis, could be explained by a delay between the onset of hypoxic injury of the liver and admission to hospital. Moreover one case was complicated by frank jaundice, an unusual feature in hypoxic hepatitis. Consequently, diagnosis and appropriate inotropic treatment were delayed resulting in progressive deterioration and eventually death of both patients. The report of these two cases and the review of other similar cases previously published, enlighten some atypical features of hypoxic hepatitis.