The initial laboratory values at the outside ED were as follows: hemoglobin, 10.5 g/dL; platelets, 89,000/μL; WBC, 21,400/μL; bilirubin (BILI), 39.6 mg/dL; alanine aminotransferase (ALT), 37 U/L; aspartate aminotransferase (AST), 140 U/L; creatinine, 3.63 mg/dL; and electrolytes, Na/K:133:6.2 mEq/L. Admission ICU laboratory values were as follows: hemoglobin, 8.8 g/dL; platelets, 68,000/μL; WBC, 25,000/μL; BILI, 51 mg/dL (primarily conjugated); ALT, 37 U/L; AST, 140 U/L; creatinine, 2.77 mg/dL; and electrolytes, Na/K:140:5 mEq/L. Alkaline phosphatase (AP) level was normal throughout. Serum lactate dehydrogenase was elevated, haptoglobulin level was low, and reticulocyte count was also elevated (10%). Peripheral blood smear showed spur cells but no schistocytes. Findings from acute and remote hepatitis panel and workup for autoimmune hepatitis were unrevealing, as were screening for HIV and a drug toxicology screen. Serum acetaminophen level was normal. CT scan of the abdomen performed at the outside ED showed cirrhotic morphology of the liver with multiple regenerating nodules and ascites (Fig 1).