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Prior to departing for Mexico, her friends and husband had mentioned that she seemed to be turning more yellow. During her time in Mexico, she reported sunbathing several hours daily and consuming two to three vodka drinks per day. She revealed that she and her husband have taken thrice-annual vacations in Mexico for the past 5?years. A review of systems revealed decreased appetite, darkening of her urine and worsening lower extremity oedema over the past 2?months. Her history revealed greater than 10?years of painful blistering of her sun-exposed upper and lower extremities. During a prior evaluation by a dermatologist for this rash and hypertrichosis, phlebotomy was recommended, but the patient declined. She denied any history of infectious hepatitis or HIV. At the time of admission, her vital signs were stable within normal limits. Examination of her skin revealed severe generalised jaundice most notable in the face and upper chest, scleral icterus, multiple dark red punctate eschars over the upper lip and forehead, several small blisters on the tip of her nose (figure 1) and 1+ pitting oedema of the lower legs bilaterally. Gross examination of her urine demonstrated a red�Cbrown hue compared to normal (figure 2). She had no abdominal pain, organomegaly, ascites, palmar erythema, spider angiomata, telangiectasias or asterixis. Figure?1 The patient's face, showing hyperpigmentation, periorbital jaundice and multiple stages of vesicular skin lesions on the forehead, nose and lips. Figure?2 The patient's urine (right) after several hours of natural light exposure, showing the reddish brown meprobamate colour characteristic of porphyria cutanea tarda. Compare to normal urine on the left. Investigations Laboratory results at this time revealed a haemoglobin 10.2?g/dL (12�C16?g/dL), mean corpuscular volume 105.6?fL (80�C99?fL), sodium 126?mEq/L (135�C153?mEq/L), potassium 2.1 (3.5�C5.3?mEq/L), aspartate aminotransferase (AST) 142?IU/L (9�C33?IU/L), alanine aminotransferase (ALT) 71?IU/L (2�C38?IU/L), alkaline phosphatase (ALP) 327?IU/L (38�C110?IU/L), total bilirubin 26.2?mg/dL (0.2�C1.1?mg/dL), direct bilirubin 14.9?mg/dL (0.0�C0.4?mg/dL), albumin 2.6?g/dL (3.4�C4.6?g/dL), ferritin 1?803?ng/mL (27�C300?ng/mL), iron saturation 96% (15�C50%) and an international normalised ratio (INR) 1.2. The patient was admitted for the evaluation of jaundice and fatigue. Her hepatitis panel, HIV test and autoimmune antibodies (antinuclear, antimitochondrial and antismooth muscle) were negative. Abdominal ultrasound and CT both demonstrated an enlarged liver with diffuse steatosis without significant ductal dilation (figure 3). Genetic testing for hereditary haemochromatosis (HH) was performed by PCR and was negative for C282Y, H63D and S65C gene mutations.