A 50-year-old Cambodian woman presented with a 3-day history of abdominal pain and confusion. Co-morbidities included Child–Pugh C cirrhosis secondary to treated hepatitis C, Type 2 diabetes mellitus, gastro-oesophageal reflux disease and fibromyalgia. She was febrile, tachycardic and hypotensive with Grade 3 encephalopathy. Abnormal examination findings included a non-blanching purpuric rash over her legs and a distended tender abdomen. Investigations demonstrated decompensated liver failure, acute kidney injury (with active urine sediment and nephrotic range proteinuria) and deranged haematological parameters.