Jaundice, Coombs Positive Hemolytic Anaemia, and Liver Failure: An Unusual Trio

Hepatitis E virus (HEV) is a single-stranded RNA virus with 20 million cases reported worldwide. Infected individuals may either remain asymptomatic or develop acute or even fulminant hepatitis. HEV has been implicated in causing Acute-on-Chronic Liver Failure (ACLF) among patients with underlying cirrhosis. Among the causes of cirrhosis, Wilson's disease is an identified cause that results in an increased accumulation of copper in the liver, brain, and other organs. It is noted that Coombs negative hemolytic anaemia is also seen in the clinical spectrum of Wilson's disease, however, Coombs positivity has not been documented. We present a case of a young female who had an undiagnosed chronic liver disease (CLD). The patient developed acute decompensation with HEV infection along with Coombs positive hemolytic anaemia. Her autoimmune hepatitis screen was negative, so the patient was worked up for other causes of CLD, which led to a diagnosis of underlying Wilson's disease. The patient was started on penicillamine and zinc acetate. However, during the disease, the patient developed acute decompensation and unfortunately expired before her transplant could take place. Our case documentation is of importance as Coombs positivity in patients with Wilson's disease has not been reported before. Attending physicians should be suspicious of Wilson's disease in a patient with Coombs positive hemolytic anaemia when other causes cannot be identified. It is also important to promptly identify any other cause of CLD to educate patients regarding factors leading to acute decompensation and progression to ACLF.