Suspected Dysphania ambrosioides-Associated Acute Liver Failure with Hepatic Encephalopathyin a Child: Importance of Early Factor V Assessment and Formal Causality Evaluation

Background: Dysphania ambrosioides contains ascaridole, a toxic monoterpene endoperoxide capable of inducing severe hepatocellular injury. Paediatric acute liver failure (ALF) associated with this plant is exceedingly rare but potentially fatal. Case Presentation: We report a 9-year-old child admitted to the paediatric intensive care unit (PICU) withWest Haven Grade II hepatic encephalopathy (HE; GCS 13/15) following family-administered D. ambrosioides decoction. Massive hepatocellular injury (AST 9,927 IU/L; ALT 70,720 IU/L), severe coagulopathy (PT 10%; INR ∼6.0; factor V 6%), elevated ammonia (112 μmol/L), and paradoxically normal bilirubin (8 μmol/L) were documented. Paracetamol was undetectable. All aetiological investigations were negative. RUCAM score: 8 (probable causality). Management and Outcome: Supportive care included neurological monitoring, vitamin K, fresh frozen plasma, lactulose, and proton pump inhibitor. Full clinical and biochemical recovery was achieved; PICU discharge on day 7, with complete normalisation confirmed at four weeks. Conclusion: Normal bilirubin does not exclude severe ALF in plant-induced toxicity. Factor V is a critical prognostic marker. RUCAM causality assessment is recommended in all suspected cases of herbal hepatotoxicity.