(407) Peliosis Hepatis in the Setting of Aromatase Inhibitor Use Leading to Intraperitoneal Hemorrhage

Introduction: Peliosis hepatis is an uncommon vascular disorder that commonly affects the liver, leading to the development of enlarged capillary beds and cystic cavities within the liver parenchyma from the proliferation of sinusoids. We present a rare occurrence of peliosis affecting multiple organs attributed to aromatase inhibitors use leading to abdominal vascular compression and intraperitoneal hemorrhage.

Description: 57-year-old woman with breast cancer diagnosed 8 years ago, started on exemestane 2 years ago. Shortly after drug initiation, abdominal pain and distension started. Scans showed diffuse hemorrhagic polycystic diseases involving the liver, spleen and spine with liver cysts replacing normal parenchyma causing severe compression of portal, hepatic, and infrahepatic IVC. Hemorrhagic polycystic diseases were visualized in diagnostic laparoscopy. Liver biopsy showed necrosis, hemorrhage and fibrotic changes consistent with peliosis hepatis. Aromatase inhibitor use was subsequently stopped. Hemorrhagic shock developed from ongoing bleeding from the liver masses. Vascular compression worsened and acute kidney injury developed from liver enlargement. ECMO and emergent transplant were not an option in her present state so the CRRT machine was used to bypass the compressed IVC and return the blood trapped in the lower body. Despite support she died from her disease.

Discussion: This case is a rare presentation of a rare disease. Peliosis can be a benign condition. It commonly affects the liver but spleen, bone marrow, lungs, and lymph nodes may be involved. Peliosis has been associated with a wide variety of etiologies including drugs, infections and malignancy however the use of aromatase inhibitors and their role in peliosis is not extensively documented. There is no consistent clinical presentation of peliosis, as the symptoms are from the mass effect of the cysts. Should a causative agent be identified, early discontinuation may halt progression. Treatment options include resection but in extreme cases liver transplantation might be considered. Although imaging is helpful, tissue biopsy is crucial for diagnosis. Although rare, severe complications include compression of the vascular structures, rupture or infarct of the peliotic cysts leading to hemorrhagic shock and death.