Acute liver failure is a condition in which there is rapid deterioration of liver function, resulting in hepatic encephalopathy and/or coagulopathy.1Deepak N.A. Patel N.D. Differential diagnosis of acute liver failure in India.Ann Hepatol. 2006; 5: 150-156PubMed Google Scholar In Latin America, complicated forms of certain tropical infections such as Plasmodium falciparum malaria, leptospirosis, rickettsial fever, typhoid fever, viral hepatitis, and rarely dengue, may present as acute liver failure. Early identification of these infections is important in reducing morbidity and mortality.2Wilder-Smith A. Schwartz E. Dengue in travelers.N Engl J Med. 2005; 353: 924-932Crossref PubMed Scopus (360) Google Scholar A 31-year-old previously healthy female presented at our clinic with a 3-day history of fever, myalgia, bilirubinuria, arthralgia, and altered mental status. She denied having any previous history of dengue or malaria. Physical examination disclosed a diffuse maculopapular rash, asterixis, and jaundice. Ten days prior to her admission she had traveled to Tolima, Colombia, a hyperendemic area for dengue infection where an ongoing outbreak due to DEN-2 (dengue virus serotype 2) was taking place. Laboratory investigations on admission showed a normal white blood cell (WBC) count and mild thrombocytopenia; blood chemistries demonstrated a bilirubin of 8.1 mg/dl, AST of 2876 UI/l, and ALT of 2120 UI/l. Her international normalized ratio (INR) was 4.47 with a prolonged prothrombin time (PT) and a prolonged partial thromboplastin time (PTT). Thick and thin smears for malaria and blood cultures were negative. Diagnostic testing for hepatitis A (IgM), hepatitis B (HBsAg, HBV DNA PCR), hepatitis C (IgG, HCV RNA PCR), hepatitis E (IgM, IgG), yellow fever (RNA PCR), Rickettsia spp (IgM/IgG), Epstein–Barr virus, cytomegalovirus, parvovirus B19 (IgM, IgG), HIV (RNA PCR), and leptospirosis (ELISA IgM and MAT) were all negative. Her dengue IgM titers were positive at high titers. There was no evidence of dengue hemorrhagic fever. A diagnosis of acute liver failure due to dengue was then made. Despite supportive efforts, our patient progressed to multiorgan failure and subsequently died. The clinical spectrum of dengue infections ranges from asymptomatic infection, to dengue fever (DF), to dengue hemorrhagic fever (DHF) and dengue shock syndrome (DHS).2Wilder-Smith A. Schwartz E. Dengue in travelers.N Engl J Med. 2005; 353: 924-932Crossref PubMed Scopus (360) Google Scholar, 3Gomez Mourao M.P. Guimaraes de Lacerda M.V. de Souza Bastos M. de Albuquerque B.C. Duarte Alecrim W. Dengue hemorrhagic fever and acute hepatitis: a case report.Braz J Infect Dis. 2004; 8: 461-464Crossref PubMed Scopus (20) Google Scholar However, sometimes dengue may manifest with atypical clinical presentations such as acute liver failure. Indeed, up to 90% of patients with DF may develop mild to moderate elevation of liver transaminases with higher levels of AST.4Kuo C.H. Tai D.I. Chang-Chien C.S. Lan C.K. Chiou S.S. Liaw Y.F. Liver biochemical tests and dengue fever.Am J Trop Med Hyg. 1992; 47: 265-270PubMed Google Scholar, 5Vinodh B.N. Bammigatti C. Kumar A. Mittal V. Dengue fever with acute liver failure.J Postgrad Med. 2005; 51: 322-323PubMed Google Scholar Liver involvement in DF and DHF has been described in Asia and the Pacific Islands, and more recently in the Americas.4Kuo C.H. Tai D.I. Chang-Chien C.S. Lan C.K. Chiou S.S. Liaw Y.F. Liver biochemical tests and dengue fever.Am J Trop Med Hyg. 1992; 47: 265-270PubMed Google Scholar, 5Vinodh B.N. Bammigatti C. Kumar A. Mittal V. Dengue fever with acute liver failure.J Postgrad Med. 2005; 51: 322-323PubMed Google Scholar, 6Poovorawan Y. Hutagalung Y. Chongsrisawat V. Boudville I. Bock H.L. Dengue virus infection: a major cause of acute hepatic failure in Thai children.Ann Trop Paediatr. 2006; 26: 17-23Crossref PubMed Scopus (65) Google Scholar However, acute liver failure has rarely been reported in the setting of DF, and most of these reports have occurred in children with DHF and have frequently been associated with DEN-3 (dengue virus serotype 3) infection.4Kuo C.H. Tai D.I. Chang-Chien C.S. Lan C.K. Chiou S.S. Liaw Y.F. Liver biochemical tests and dengue fever.Am J Trop Med Hyg. 1992; 47: 265-270PubMed Google Scholar, 5Vinodh B.N. Bammigatti C. Kumar A. Mittal V. Dengue fever with acute liver failure.J Postgrad Med. 2005; 51: 322-323PubMed Google Scholar, 6Poovorawan Y. Hutagalung Y. Chongsrisawat V. Boudville I. Bock H.L. Dengue virus infection: a major cause of acute hepatic failure in Thai children.Ann Trop Paediatr. 2006; 26: 17-23Crossref PubMed Scopus (65) Google Scholar Dengue virus liver injury may occur due to its ability to replicate in liver cells leading to hepatocellular injury with development of Councilman bodies.7Carvalho de Macedo F. Nicol A.F. Cooper L.D. Yearsley M. Cordovil Pires A.R. Nuovo G.J. Histologic, viral, and molecular correlates of dengue fever infection of the liver using highly sensitive immunohistochemistry.Diagn Mol Pathol. 2006; 15: 223-228Crossref PubMed Scopus (58) Google Scholar, 8Couvelard A. Marianneau P. Bedel C. Drouet M.T. Vachon F. Henin D. et al.Report of a fatal case of dengue infection with hepatitis: demonstration of dengue antigens in hepatocytes and liver apoptosis.Hum Pathol. 1999; 30: 1106-1110Abstract Full Text PDF PubMed Scopus (170) Google Scholar In fact, in situ detection of DNA fragmentation and apoptotic hepatocytes in association with dengue virus-infected hepatocytes has suggested that hepatocytes are important sites of viral replication and that dengue virus induces apoptosis in vivo.7Carvalho de Macedo F. Nicol A.F. Cooper L.D. Yearsley M. Cordovil Pires A.R. Nuovo G.J. Histologic, viral, and molecular correlates of dengue fever infection of the liver using highly sensitive immunohistochemistry.Diagn Mol Pathol. 2006; 15: 223-228Crossref PubMed Scopus (58) Google Scholar Our case demonstrates that in addition to classic DF and DHF, testing for dengue should also be pursued among travelers returning from tropical areas endemic for dengue presenting with acute liver failure. Conflict of interest: No conflict of interest to declare.