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A 15 year old girl presented to an internal medicine ward with a two day history of jaundice and intermittent, high grade fever. Low grade fever and constitutional symptoms had been present for three weeks, during which the only medication taken was ibuprofen. Her mother recalled having found rat excrement in her knapsack, after the girl had returned from a rural resort, a few days before the onset of her illness. All family members had eaten seafood on a single occasion, two weeks before admission. She was not sexually active, had never been transfused, had no known exposure to hepatotoxic chemicals, and did not drink alcohol or use recreational drugs. There was no family history of liver disease or of recent travel to foreign countries. On physical examination, she was alert and cooperative. There was hepatomegaly and diffuse abdominal tenderness; ascites and stigmata of chronic liver disease were absent.
Laboratory data are shown in table 1. There were no schistocytes on the blood smear, nor were corneal opacities found at slit lamp examination. Abdominal ultrasound and duplex Doppler sonography confirmed the presence of marked liver enlargement (longitudinal diameter 20 cm); spleen longitudinal diameter was 14 cm. Bile ducts were not dilated, the hepatic artery, portal vein and hepatic veins were patent, and there was no free peritoneal fluid.
In the next six hours confusion, anuria, and respiratory distress ensued. The patient was transferred to an intensive care unit and a liver biopsy was performed (fig 1).
What does the liver biopsy show?
What is the most likely diagnosis?
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