A 21-year-old Female with Acute Liver Failure and Hemolytic Anemia

Had an interesting case this month that my Blood Bank team was involved with. I've changed some of the information to protect her privacy.

A 21-year-old female presented with a 5 week history of fatigue, anorexia, and mild jaundice. She was previously healthy with no past medical history, no medications, and no drug use. The initial workup showed a normochromic, normocytic anemia (Hgb 11.5) and increased liver function tests and was negative for infectious mononucleosis and viral hepatitis. Just a few days after this basic workup her course worsened and she became more severely jaundiced and developed dark urine and right upper quadrant pain. She was admitted to a referring institution and the workup showed the following:

Afebrile and vital signs stable
Scleral icterus, jaundice, splenomegaly, and RUQ pain on exam

WBC: 13.5 H
Hgb: 6.5 L
Plt: 178
Creatinine: 2.2 H

ALT: 13
AST: 147 H
Alk phos: 17 L
Tbili: 42.9 H
Dbili: 12.6 H

INR: 3.1 H
Albumin: 2.3 L

LDH: 659 H
Haptoglobin: undetectable L
Retic: 11.79 H
Direct antiglobulin: neg.
Blood type: O+, Ab screen neg.

ANA: within normal limits
Serum pregnancy test: neg.

Does anyone have a diagnosis? I'll post it in a week with follow up photos in a new post and/or comment.

A 30-year-old man with an intracranial parafalcine mass

We received an unusual case on our neuropathology service this week. The specimen was a 4 cm frontal, extra-axial mass that was dural-based, abutting the falx cerebri. MRI showed intense enhancement with surrounding vasogenic edema and a small dural tail. There was only mild mass effect and diffusion weighted imaging (DWI) showed no diffusion restriction. Cerebral arteriography showed a hypervascular lesion. Left middle meningeal artery embolization was performed preoperatively. At craniotomy the tumor was liquid and necrotic-appearing and the excised specimen was sent to us for pathological examination. The histological appearance is depicted below (click on photos to get higher resolution):

Glassy, eosinophilic cytoplasm with inclusions

Atypical cytology with some prominent nucleoli (occasional mitoses were also identified [~1-2 per 10 high-powered fields])

Focal areas of necrosis and hemorrhage

MIB-1 (Ki-67) immunostain showing a 15-20% proliferation rate.

Additionally, a vimentin immunostain showed strong diffuse cytoplasmic positivity and an EMA immunostain showed positive membrane staining. Cytokeratin immunostain was negative. How would you diagnose this case?