An 80 year old man with a five day history of vomiting, renal failure and jaundice.

CASE REPORT An 80 year old man was admitted to hospital with a one month history of progressive malaise and a five day history of vomiting, renal failure and jaundice. He had a past history of a right hip replacement but otherwise had been in reasonable health. A provisional diagnosis of hepatitis had been made by his local medical officer and he was admitted to hospital for further management. On admission he had mild peripheral oedema. His pulse was 94 beats per minute, respiratory rate 18 per minute, blood pressure 145/70 mmHg and temperature 36.4°C. His liver function tests revealed a bilirubin of 64 μmol/L, ALT 1240 U/L and ALP 40 U/L. His plasma creatinine was 0.22 mmol/L. He had no history of recent exposure to hepatotoxins, drank alcoholic cider occasionally and during his 5 day stay in hospital, serology tests for HAV, HBV, HCV, HEV, CMV and EBV were all negative. A diagnosis of ‘sepsis’ was made, although there was no clinical evidence of infection and his temperature, white cell count and Creactive protein estimations remained within normal limits. However, as his hepatic and renal functions progressively deteriorated, admission to the intensive care unit (ICU) was requested. At this stage he had clinical features of peripheral cyanosis (e.g. cyanosis of ears, fingers and knees) his blood pressure was 160/70 mmHg, pulse 88 beats per minute and pulse oximetry revealed a saturation of 98% on nasal oxygen at 4 L/min. The arterial blood gases revealed a PO2 of 76 mmHg, PCO2 of 18 mmHg and a pH of 7.45. A biochemical profile performed on admission to the ICU (Figure 1) led to the diagnosis.