We report a case of fulminant hepatic failure due to the Budd–Chiari syndrome following preservation with a tropical fever. A young lady came with fever, altered mental status, jaundice, and renal failure. Following tropical workup, it was diagnosed as a case of leptospirosis (WHO Faine's criteria) with multi-organ dysfunction. Despite adequate antimicrobial cover, she progressed to hepatic coma (hyperammonemia) and was noted to have worsening conjugated hyperbilirubinemia. Following history review and evaluation for other causes of hepatic failure, hepatic vein thrombosis was detected in addition to the presence of antibodies against Leptospira antigen. Further studies into the causes of thrombosis and persistent hemoconcentration despite aggressive fluid resuscitation led to the diagnosis of polycythemia vera (cytometric analysis). During her stay, she further worsened despite aggressive organ support including dialysis but she succumbed to gram-negative sepsis that occurred during her stay in ICU. This is an interesting and rare case of leptospirosis that unveiled a case of previously asymptomatic polycythemia vera.
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