Abstract Introduction Acute-on-chronic liver failure (ACLF) is often precipitated by infection, but the contribution of psychological factors, particularly in patients with persistent fever and neuropsychiatric symptoms, is unclear. Case description A 44-year-old man with hepatitis B–related cirrhosis presented with a 21-day history of high fever (39.4 °C), jaundice and acute mania. Investigations showed marked hyperbilirubinaemia and coagulopathy consistent with ACLF but no clear infectious focus. Daily artificial liver support and empirical meropenem improved bilirubin levels and consciousness, yet fever and manic symptoms persisted. On day 6, structured psychotherapy with quetiapine and valproate was initiated; within 48 hours the fever resolved and manic features progressively abated. Imaging on day 14 revealed suppurative cholecystitis, treated with interventional therapy, and by day 25 liver function and Child–Turcotte–Pugh score had substantially improved. Discussion The temporal association between psychological intervention, defervescence and improvement in manic symptoms suggests that chronic psychological stress may have amplified systemic inflammation and fever expression in this ACLF patient. Learning point(s) In ACLF with unexplained fever and mania, clinicians should consider psychological contributors alongside infectious causes, and multidisciplinary care integrating artificial liver support, judicious anti-infective therapy and psychotherapy may improve outcomes.
Yan Bo (Mon,) studied this question.