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De novo mutations in POLG presenting with acute liver failure or encephalopathy.

Historically, mitochondrial respiratory chain disorders have been recognized as a multisystemic disease with predominantly neuromuscular dysfunction (1). To date, most patients with mutations in POLG have presented with predominantly neurological features of headaches or focal seizures (2,3). In 1 study, end-state hepatic disease developed in only 2 of 26 cases (2). In another study, the only patients who experienced hepatic disease had been exposed to sodium valproate (3,4). Viral infection may be temporally associated with the development of acute liver failure in pediatric patients (5). However, the majority of children who contract viral infections do not experience liver failure. This suggests that there must be host factors that differentiate those children who do experience liver failure.