Acute liver failure, defined as hepatic encephalopathy developing within 12 weeks of jaundice in the absence of a previous history of symptomatic liver disease,1 is a medical emergency. Accurate recognition of the underlying disease is crucial to enable specific therapy, when available, to be instituted. Rowbothamet al (see page 576), in the most comprehensive examination of this topic to date, discuss the importance of malignant hepatic infiltration as a cause of acute liver failure. This is, however, an undoubtedly rare cause for this presentation in the UK, responsible for only 0.44% of all cases of liver failure admitted to the King’s Unit since 1978.

This syndrome can occur in a number of scenarios. Firstly and most importantly, patients with no previous history of malignancy may develop fulminant liver failure and present as a diagnostic problem. Secondly, acute liver failure may develop in a patient with previously diagnosed malignancy but without known liver involvement. Finally, fulminant liver failure may be seen as a terminal event in a patient already known to have primary or secondary hepatic malignancy. Such patients, although not fulfilling the strict diagnostic criteria for acute liver failure, may provide further insight into the likely mechanisms of liver failure in malignancy.

In a patient presenting with acute liver failure with no cause apparent, the diagnosis of hepatic infiltration should be considered but may be surprisingly difficult to …