Hepatitis A virus is the most common acute viral hepatitis worldwide with approximately 1.5 million cases annually. Hepatitis A virus infection in general is self-limited. In rare cases, hepatitis A virus infection may cause renal failure, hemolytic anemia, and/or cholestasis. We report the first case of acute cholestatic hepatitis A virus infection complicated by hemolytic anemia, and renal failure in one patient. A 42-year-old Caucasian male presented with cholestasis, hemolytic anemia and renal failure after consuming street tacos in Central and South America while on a business trip. His protracted course required corticosteroid therapy, multiple sessions of plasma exchange, and numerous units of packed red blood cells. This case demonstrates the importance of vaccination in high-risk adults. A prompt diagnosis of acute hepatitis A virus infection is essential, as uncommon presentations may delay diagnosis leading to permanent morbidity and potentially death in fulminant cases. We also demonstrate the efficacy of treatment of cholestatic hepatitis A virus infection, hemolytic anemia, and renal failure with corticosteroids and plasma exchange. 1. Introduction Hepatitis A virus (HAV) is the most common acute viral hepatitis worldwide and in general has a self-limited course [1, 2]. Extrahepatic manifestations of hepatitis A infection are uncommon. Jaundice, dark urine, fatigue, loss of appetite, and nausea are reported in over 80% of patients with HAV [3]. Rarely has renal failure, hemolytic anemia, and cholestasis been described in patients with HAV infection We describe a gentleman with protracted course of cholestatic hepatitis due to HAV infection, complicated by renal failure and hemolytic anemia. This case underscores the importance of vaccination in high-risk adults and prompts diagnosis of acute HAV infection, as uncommon presentations may delay diagnosis leading to permanent morbidity and potentially death in fulminant cases. This is the first case of acute cholestatic hepatitis A virus infection with associated hemolytic anemia and renal failure. 2. Case Report A 42-year-old Caucasian man with no significant past medical history presented with one month of nausea, nonbilious vomiting, intermittent fever, anorexia, and jaundice. His symptoms started one week after eating street tacos while traveling through Mexico, Peru, and Argentina for business. A local physician in Argentina initially treated him with 10 days of amoxicillin and 6 days of methylprednisolone followed by 5 days of azithromycin with minimal improvement. He traveled back to
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