A 39-year-old male was admitted with joint pain, skin plaques, and fever. He was diagnosed with psoriasis 20 years ago and was treated with local steroids. On this admission, he had fever (39 °C, tympanic), jaundice, pain in the right upper abdominal region, pain at the axial and peripheral joints, disseminated psoriatic rashes, a sausage-shaped digit (left hand, third finger), pustules on psoriatic rashes on both ankles, and pitting of all fingernails. Laboratory investigations included a white cell count of 18.2 x 109/l, alanine aminotransferase (ALAT) level 310 IU/l, aspartate aminotransferase (ASAT) level 220 IU/l, gamma glutamyl transpeptidase 256 IU/l, alkaline phosphatase 600 IU/l, and total bilirubin 87.2 µmol/l (n = 0-17). He had right-sided sacroiliitis on MRI. Blood cultures were obtained and he was given antibiotics (piperacillin/tazobactam). Blood cultures remained sterile. Hepatobiliary ultrasound and magnetic resonance cholangiography remained negative. Fever, rash, and joint pain persisted. A liver biopsy was obtained (figures 1 and 2).