Adult onset Still's disease (AOSD) is a well characterized rheumatoid disorder with frequent liver involvement. This is usually asymptomatic but severe hepatic failure has occasionally been reported. We describe a 44-year-old woman who developed acute liver failure 2 months after presenting symptoms of AOSD. Full etiologic evaluation was done and all other causes of liver failure were excluded. She underwent emergency orthotopic liver transplantation but developed disseminated intravascular coagulation with acute renal failure, seizures, and coma, and died after 48 hours.