Dr. Gardner presented a great case of a man who was recently started on steroids that developed diffuse weakness and vesicular facial rash. His labs revealed acute liver failure (hepatocellular pattern with AST and ALT in 10,000s), thrombocytopenia, and a ferritin of 15,000! Our residents discussed the differential for transaminases greater than 1000, and our graduating resident, Dr. Jared Huber, gave an excellent mneumonic of "VITAMIN-C" to help us rememeber.
We also were reminded of causes of elevated ferritin, including disseminated fungal and viral infections. Because of the severity of this man's presentation, numerous medical teams were consulted. The diagnosis of HLH was entertained, but the patient did not meet criteria, and BM biopsy was negative. Ultimately, he was found to had disseminated HSV (confirmed with skin biopsy) causing his acute liver failure and hyperferritinemia. This case is a great reminder that when you are in a diagnostic dilemma, it can be helpful to go back to the presentation (his vesicular facial rash) and you may just find the diagnosis.