What is the diagnosis and management for a neonate presenting with excessive lethargy, mildly deranged liver enzymes, highly raised ferritin levels, and elevated alpha-fetoprotein (alpha-fetoprotein)?

Neonatal Hemochromatosis: Diagnosis and Immediate Management

This neonate most likely has neonatal hemochromatosis, a life-threatening condition requiring urgent antioxidant and iron-chelation therapy, with immediate referral to a pediatric liver transplant center. 1, 2

Primary Diagnosis

Neonatal hemochromatosis is the leading cause of acute liver failure in neonates requiring transplantation, presenting within the first days to weeks of life with severe hepatic injury and iron overload. 1 The constellation of:

• Excessive lethargy (indicating hepatic encephalopathy or severe metabolic derangement)
• Mildly deranged liver enzymes (often underestimate severity in neonates)
• Highly raised ferritin levels (indicating iron overload)
• Elevated alpha-fetoprotein (markedly elevated, often 10-fold higher than normal neonatal values)

...is pathognomonic for neonatal hemochromatosis. 2

Critical Diagnostic Confirmation

Obtain immediately:

• Iron saturation (transferrin saturation) - will be markedly elevated in neonatal hemochromatosis 2
• Coagulation studies (PT/INR, PTT) - coagulopathy indicates hepatic synthetic failure and poor prognosis 3, 1
• Albumin - hypoalbuminemia confirms severe hepatic dysfunction 3
• Fractionated bilirubin - direct hyperbilirubinemia expected 1
• Complete blood count - may show anemia or thrombocytopenia 4

Tissue confirmation via biopsy is NOT required before initiating treatment, as the urgency of therapy precludes waiting for histological confirmation. 2 The biochemical profile (raised ferritin, iron saturation, and very high alpha-fetoprotein) is sufficient to begin treatment. 2

Differential Diagnoses to Exclude

Tyrosinemia Type 1

• Would show elevated blood or urine succinylacetone levels (diagnostic) 3
• AFP elevation occurs but is not as dramatically elevated as in neonatal hemochromatosis 3
• Ferritin may be elevated but not to the degree seen in neonatal hemochromatosis 3
• Check plasma tyrosine and succinylacetone immediately 3

Alpha-1 Antitrypsin Deficiency

• Accounts for 7-18% of neonatal cholestasis cases 3, 1
• Presents with neonatal cholestasis in 11% of PI*ZZ infants 3
• Obtain alpha-1 antitrypsin phenotyping by isoelectric focusing 1
• Does NOT typically present with markedly elevated ferritin 3

Hepatoblastoma

• Rare in neonates but can present with elevated AFP 4
• Would show a discrete mass on imaging (ultrasound or MRI) 4
• Ferritin elevation would be less pronounced 4
• Obtain urgent abdominal ultrasound 1

Immediate Management Protocol

Initiate treatment immediately without waiting for tissue confirmation:

1. Antioxidant therapy - N-acetylcysteine, vitamin E, selenium 2
2. Iron chelation therapy - deferoxamine or deferasirox 2
3. Correct coagulopathy - fresh frozen plasma, vitamin K 2
4. Correct hypoalbuminemia - albumin infusions 2
5. Urgent referral to pediatric liver transplant center - mandatory for any neonate with acute liver failure 1

Prognostic Indicators

Poor prognostic factors include:

• Coagulopathy (elevated PT/INR) 3, 1
• Hypoalbuminemia 3
• Hard hepatomegaly 1
• Elevated bilirubin 3

Both neonates in the landmark case series made complete recovery with early antioxidant and chelation therapy, emphasizing the critical importance of rapid diagnosis and treatment initiation. 2

Critical Pitfalls to Avoid

• Do NOT delay treatment waiting for liver biopsy - the requirement for early therapy precludes biopsy 2
• Do NOT assume elevated AFP is normal for age - while AFP is physiologically elevated in neonates, values in neonatal hemochromatosis are typically 10-fold higher than normal neonatal values 3
• Do NOT interpret isolated ferritin elevation as inflammatory - when combined with elevated iron saturation and AFP in a sick neonate, this indicates iron overload disease 2
• Do NOT miss sibling history - a hyperferritinemic sibling supports the diagnosis 2