Case Report Two Fatty Liver Conditions Masquerading as Autoimmune Hepatitis Jonathan David Hendrie , 1 Mary Crouse Blumer , 1 Hubert Henry Fenton, 2 and Gary Anthony Abrams 3 1 Prisma Health-Upstate, University of South Carolina School of Medicine-Greenville, Department of Medicine, 701 Grove Rd., Greenville, SC 29605, USA 2 Prisma Health-Upstate, Department of Pathology, 701 Grove Rd., Greenville, SC 29605, USA 3 Prisma Health-Upstate, University of South Carolina School of Medicine-Greenville Department of Medicine, Division of Gastroenterology & Liver Center, 890 W. Faris Rd., Suite 100, Greenville, SC 29605, USA Correspondence should be addressed to Jonathan David Hendrie; jonathan.hendrie125@gmail.com Received 16 August 2020; Revised 28 January 2021; Accepted 2 March 2021; Published 9 March 2021 Academic Editor: Haruki Komatsu Copyright © 2021 Jonathan David Hendrie et al. is is an open access article distributed under the Creative Commons AttributionLicense,whichpermitsunrestricteduse,distribution,andreproductioninanymedium,providedtheoriginalworkis properly cited. Acute fatty liver of pregnancy (AFLP) is a rare obstetric condition that classically presents in the third trimester or early postpartumperiodandcanleadtoliverfailureanddeath.OnlysixsecondtrimesterAFLPcaseshavebeenreportedintheEnglish literature.WepresenttheearliestcaseofAFLPat15weeksofgestationconfoundedbyahightiteranti-nuclearantibody(ANA >1:1280)andconcernforautoimmunehepatitis.Ourpatienthadintrauterinefetaldemisewithpromptdilationandevacuation. Sepsis and multisystem organ failure ensued, and she was transferred to a liver transplant center where she expired without further intervention. 1. Introduction Acute fatty liver of pregnancy (AFLP) is a rare and po- tentially fatal condition characterized by microvesicular steatosis and liver failure. e pathophysiology remains unclear,butresearchhasimplicateddefectivemitochondrial fatty acid oxidation as a contributing factor. AFLP typically presents in the third trimester or early postpartum period, but rare cases have been described in the second trimester [1–6].DiagnosisisusuallybasedontheSwanseacriteria[7] in conjunction with serologic and biochemical testing al- though liver biopsy can be performed under certain cir- cumstances. Treatment involves early diagnosis, prompt fetal delivery, and intensive supportive care with recovery expected over the ensuing days to weeks [8]. 2. Case Report A41-year-oldgravida4para2patientat15weeksand5days of gestation (based on ultrasound) presented to an outside hospital with decreased appetite and severe vomiting. She had WHO class III obesity (BMI 45.1kg/m 2 ) but was oth- erwisehealthy.Initiallaboratorytestsshowedawhiteblood cell count (WBC) 14 k/µL, hemoglobin (Hgb) 13.7g/dL, platelets (PLT) 354 k/µL, normal blood smear, aspartate aminotransferase(AST)354IU/L,alanineaminotransferase (ALT) 574 IU/L, alkaline phosphatase (ALP) 125 IU/L, and total bilirubin (TB) 4.8mg/dL. Abdominal ultrasound and magnetic resonance cholangiopancreatography showed hepatic steatosis, pericholecystic fluid, and gallbladder wall thickening. Further workup revealed a positive anti-nuclear Hindawi Case Reports in Hepatology Volume 2021, Article ID 8820350, 5 pages https://doi.org/10.1155/2021/8820350