Acute Liver Failure in an Adolescent Following Use of the Synthetic REV-ERB Agonist SR9009

Drug-induced liver injury (DILI) is a leading cause of acute liver failure (ALF) and an increasingly recognised consequence of unregulated performance-enhancing supplements. We report a 17-year-old male who presented with progressive jaundice and rapidly evolving ALF temporally associated with ingestion of the synthetic REV-ERB agonist SR9009. Despite early treatment with N-acetylcysteine, he developed worsening coagulopathy, hyperbilirubinaemia, ascites and Grade 3 hepatic encephalopathy, necessitating emergency liver transplantation. Extensive investigation excluded viral, autoimmune, metabolic and obstructive causes. Liver biopsy demonstrated severe hepatocellular injury with confluent and multiacinar necrosis, consistent with severe DILI. Following transplantation, liver biochemistry and synthetic function improved rapidly. This case highlights the hepatotoxic potential of unregulated supplements, the importance of obtaining a detailed exposure history in young patients with acute liver injury and the need for early recognition of progressive liver failure requiring timely referral to a liver transplant centre.