Autoimmune hepatitis associated with an abnormally low ceruloplasmin level

A 44-year-old female with a remote history of autoimmune hepatitis (AIH) in remission presented with fatigue and scleral icterus, and developed fulminant liver failure within 24 hours of admission. The initiation of therapy was delayed due to the incidental finding of cholelithiasis and suspected cholecystitis. The patient was initiated on empiric antibiotics, but deteriorated rapidly. The clinical picture and history was consistent with acute severe AIH, but a low serum ceruloplasmin level and laboratory features of hemolytic anemia pointed towards fulminant Wilson’s disease. She was initiated on pulse-dose steroids, but ultimately expired from acute severe liver dysfunction and multi-organ failure. The case highlights the clinical features of AIH in the acute setting, and seeks to discuss the role of serum ceruloplasmin levels in patients with liver disease.