A 49-year-old man presents with worsening confusion since waking up six hours ago. His wife noticed that his eyes have been yellow-tinged for the same duration. Further questioning reveals multiple bouts of nausea and vomiting, insomnia, daytime drowsiness, agitation, and irritability during the preceding four days. His medical and surgical histories are unremarkable. He is not on any medications. There is no history of allergies. He has regularly consumed an estimated 10 units of alcohol per week for the last two decades and had almost doubled his intake over the last three months, after losing his job as a manual worker. There is no history of promiscuity, recreational drug use, or suicidal ideation or attempts. A complete blood count is only significant for a hemoglobin level of 10.5 g/dL (normal:11-18). Serum electrolytes and renal functions are within normal parameters.
AST: 1670 IU/L (8-48) ALT: 2100 IU/L (7-55) ALP: 653 IU/L (45-115) Total bilirubin: 5.6 mg/dL (0.2-1.2) Direct bilirubin: 4.2 mg/dL (0.1-0.4) INR: 8.0 (0.8-1.3)
Hepatitis A antibody (HAAb): negative Hepatitis B core antibody (HBcAb): negative Hepatitis B surface antigen (HBsAg): negative Hepatitis C antibody: negative
Serum acetaminophen levels are not elevated.
The ultrasound confirms the presence of hepatomegaly, with a normal echotexture. No other abnormalities are seen. A doppler study shows normal blood flow in the portal venous system and hepatic vasculature.