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We report the case of a 36-year-old male who was referred to us with a provisional diagnosis of ethanol-related acute on chronic liver failure with ascites, encephalopathy, and altered liver function tests (LFTs). The patient underwent a living donor liver transplant. Posttransplant, he had an uneventful recovery till postoperative day (POD) day 7 when he developed tachycardia and low-grade fever. The immunosuppression has to be withheld till POD 26. The patient later developed deranged LFT and an initial liver biopsy showed features of acute cellular rejection. He also had ongoing tachycardia; thus, immunosuppression was withheld. Subsequent to that patient developed rapid progression from progressive early to chronic rejection (CR) within 78 days posttransplant. The patient initially responded to antithymocyte globulin, but finally succumbed to fungal infection. CR usually occurs over 6 months posttransplant. The occurrence of CR was noted very early in the index patients. This case highlights the importance of a basic step-wise approach to a case post liver transplant. It also highlights the importance of specialized liver histopathology aiding in early diagnosis.

We report the case of a 36‑year‑old male who was referred to us with a provisional diagnosis of ethanol‑related acute on chronic liver failure with ascites, encephalopathy, and altered liver function tests (LFTs). The patient underwent a living donor liver transplant. Posttransplant, he had an uneventful recovery till postoperative day (POD) day 7 when he developed tachycardia and low‑grade fever. The immunosuppression has to be withheld till POD 26. The patient later developed deranged LFT and an initial liver biopsy showed features of acute cellular rejection. He also had ongoing tachycardia; thus, immunosuppression was withheld. Subsequent to that patient developed rapid progression from progressive early to chronic rejection (CR) within 78 days posttransplant. The patient initially responded to antithymocyte globulin, but finally succumbed to fungal infection. CR usually occurs over 6 months posttransplant. The occurrence of CR was noted very early in the index patients. This case highlights the importance of a basic step‑wise approach to a case post liver transplant. It also highlights the importance of specialized liver histopathology aiding in early diagnosis. [ABSTRACT FROM AUTHOR]