A bolt out of the blue: a case of unexpected acute liver failure.

INTRODUCTION We describe an unusual case of acute hepatitis leading rapidly to acute liver failure. CLINICAL PICTURE Our patient had known chronic hepatitis B with a regenerating nodule confirmed on imaging and histology. He was admitted initially for abdominal discomfort after a trip to China, and investigations showed acute hepatitis with alanine transaminase (ALT) and aspartate transaminase (AST) at 678 and 557 U/L, respectively. Initial differential diagnoses were acute exacerbations of chronic hepatitis B, and viral hepatitis A or E. However, acute Budd- Chiari syndrome was diagnosed on computed tomography (CT) scan of the abdomen, which showed extensive thrombosis of the hepatic vein, all the intrahepatic branches, inferior vena cava, up to the right atrium. TREATMENT Due to the extensive nature of the thrombus, radiological or surgical intervention could not be performed. OUTCOME The patient was managed conservatively but progressed rapidly and died of acute liver failure 16 days after presentation. CONCLUSION Our case highlights the rapidity of progression of acute Budd-Chiari syndrome. Diagnosis and management of Budd-Chiari syndrome are discussed.