Nyctalopia as the presenting symptom of new onset alcoholic liver failure

Vitamin A plays a crucial role in retinal phototransduction, and deficiency of this essential nutrient commonly produces nyctalopia as its earliest symptom. In the developing world, vitamin A deficiency is usually due to dietary scarcity, while in the developed world, this occurs rarely, and is confined to patients with psychiatric disease or restricted diets. In the United States, vitamin A deficiency is usually secondary to fat malabsorption or difficulties with Vitamin A metabolism such as in gastric bypass, inflammatory bowel disease or liver disease. We describe a case of vitamin A deficiency that was initially attributed to poor diet, but was ultimately revealed to be the presenting sign of new onset liver failure.