PMC8024064_01
Liver function tests before, during, and after 2 cycles of nivolumab. The dates are numbered starting with the first day of the first cycle of nivolumab. AST: aspartate aminotransferase; ALT: alanine aminotransferase; day 1*: start of the 1st cycle of nivolumab; day 14*: start of the 2nd cycle of nivolumab; day 22*: 1st dose of corticosteroids. The graph shows the rapid increase in liver function tests after the patient began taking nivolumab and the minor response after being treated with corticosteroids. It also depicts the timeline until the patient perspired.
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Then, one week after that, his right upper quadrant abdominal pain worsened, and he was found to have an aspartate aminotransferase (AST) level of 310 U/L, alanine aminotransferase (ALT) of 187 U/L, alkaline phosphatase of 713 U/L, and total bilirubin of 3.8 mg/dL (Figure 1). However, on the fourth hospital day (day 26 in Figure 1), his condition dramatically declined.
PET/CT scan of the abdomen. (a) One month prior to the first cycle of nivolumab: multiple intrahepatic lesions. (b) Day 22 after the first cycle of nivolumab: significant hepatomegaly due to hepatitis, significant increased metabolic activity of the entire liver, and new abdominal ascites. The PET/CT scan of the patient abdomen depicts the changes in the patient's liver before and after starting nivolumab. The second picture shows the large size of the liver when the patient developed autoimmune hepatitis.
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This suggested a diffuse inflammatory process involving the entire liver rather than progression of metastatic disease which would have shown more heterogeneous FDG avidity corresponding to the sites of tumor activity (Figure 2).