CASE REPORT
31 Year Old, otherwise healthy female with no significant past medical history presented to ED with complaints of yellow discoloration of her urine followed by yellow discoloration of her eyes associated with headache, nausea, and vomiting.She also had abnormally high liver enzymes with AST and ALT as high as the 2000’s with an associated conjugated hyperbilirubinemia. Before that, she had decreased appetite and some vague abdominal pain for the past 2 days along with the sensation of constipation. She took a probiotic and some cranberry pills which didn't seem to help improve her urine color and abdominal discomfort. Family history was negative for liver disease and autoimmune disorders. She denies a history of IV drug use, recent NSAIDs use, and recreational medications such as ecstasy or amphetamines or cocaine.All the laboratory workup for infections as well as autoimmune etiology were negative. She had an Ophthalmology/optometry examination in August 2019 and no Kayser-Fleischer rings were seen. USG abdomen and MRCP shows gallbladder wall thickening with gallbladder wall measuring up to 4.5 mm and no cholelithiasis/choledocholithiasis. Her gamma globulin level was normal, Monospot negative, negative for hepatitis A, B,and C and HIV screen. Liver enzymes remain elevated (>1000) in a predominantly hepatocellular pattern with cholestasis and decided to do the outpatient liver biopsy next week and discharged, but the Patient began to develop RUQ pain, nausea, vomiting, and worsening jaundice yesterday which prompted her to return to ED. 
Table 1:
Dates2/233/224/245/167/18
AST (U/L)16051007697156101
ALT (U/L)186574746111253
Alk.Phosphatase (U/L)301262275261245
Bilirubin (mg/dl)5.33.73.21.41.2
Ferritin (mg/dl)29161579782532
To differentiate the suspicious cause of conjugated hyperbilirubinemia with transaminitis in 1000s we decided to do a liver biopsy.A liver Biopsy was performed and it demonstrated subtotal hepatic necrosis with severe inflammation and a very small amount of iron and fibrosis in the liver (Table 2). PCR of blood identifies a single mutation C282Y identified. She is being treated with phlebotomy and her liver enzymes improve significantly.
Table 2: