Case Presentation:

A 7-year-old female presents to the emergency department (ED) complaining of fever and abdominal
pain.
History of Present Illness
Parents report that 2 weeks ago the patient had a fever to 38.8 C), mild cough, vomiting, and diarrhea
which resolved without treatment. Today she began to have dark-colored urine and her mother noticed
yellowish discoloration of her skin and sclera, and a 3-kg weight gain compared to her last appointment a
month ago.

Past Medical History

The child was born at term by spontaneous vaginal delivery with no medical complications and
discharged home with her mother. She has received all immunizations to date, but did not get influenza
vaccine this year. She has never been hospitalized and does not have any chronic illness.
Past Surgical History
Not contributing.
Family History
Parents are non-consanguineous and healthy. Her 14-year-old brother was recently sick with an acute
upper respiratory infection, which resolved without any medical intervention.
Upon arrival to ED
The patient is evaluated in the ED and initially noted to be sleepy but rouasable. She is able to answer
questions with prompting from her mother. Vital signs are stable: temperature 38.9 C, heart rate 120 bpm,
respiratory rate18 breaths per minute, and blood pressure 100/65 mmHg.
She complains of itching in her arms and legs and right upper quadrant abdominal pain. She is noted to
have scleral icterus. Laboratory studies are obtained and the results are shown below. The ammonia level
is found to be 86 μg/dL.

Laboratory Results:
Complete blood count:
WBC 26 000/mm3
Hb. 10 g/dL
Platelet count 85 000/mm3
Neutrophils 8%
Lymphocytes 22%
Complete metabolic profile and liver function test results.

Na 145 Cl 100 BUN Glucose ALT Bilirubin PT 18 s Fibrinogen 250 mg/dL

mEq/L mEq/L 26 mg/dL 90 mg/dL 980 U/L 6.1 mg/dL

K 3.5 CO2 24 Creatinine Albumin AST INR 2.5 PTT 40 s

mEq/L mEq/L 1.4 mg/dL 2.9 g/dL 765 U/L
What is the condition the patient is having?
Acute liver failure

Based on the data given, what are the differential diagnoses for this child?

1. Drug toxicity
2. Infection
3. Immune system dysfunction
4. Hypoperfusion
5. Metabolic disease

What additional testing would be warranted?

1. An infectious evaluation should be performed to determine a potential
viral cause of acute liver failure
2. Immune markers
3. (ANA, AMA, ASMA)
4. Serum Ferritin
5. Liver ultrasound with Doppler
6. Serum Ceruloplasmin