Unusually Low Serum Alkaline Phosphatase Activity in a Patient with Acute on Chronic Liver Failure and Hemolysis.

A 28-year-old male with acute on chronic liver failure (ACLF) and hepatic encephalopathy had deranged liver function with curiously low level (0-15 IU/L) of serum alkaline phosphatase (ALP). Peripheral smear examination suggested hemolytic anemia. The finding of persistent low ALP, after ruling out pre-analytical causes, in ACLF has been reported in Wilson's disease (WD) with/ without autoimmune hemolytic anemia (AIHA). Definitive evidences of WD were not seen in our case. Positive DCT and histological features suggest a diagnosis of autoimmune hepatitis with secondary hemochromatosis and cholangitis. Low ALP might not always be a determinant of bile duct pathology in patients of ACLF with AIHA.