INTRODUCTION: An estimated 4.1 million people of US have been exposed to hepatitis C (HCV), 70% of which were born between 1945 and 1964, known as the “baby boomer” cohort. While a majority of patients with acute HCV go undetected, 15% present as acute hepatitis. CASE DESCRIPTION/METHODS: A 77 year old woman presented with right upper quadrant pain, jaundice, loss of appetite and malaise for 2 weeks. She denied recent travel, alcohol or drug use, prior blood transfusions, acetaminophen ingestion and use of herbal supplements. Her exam was remarkable for scleral icterus and RUQ tenderness. Initial laboratory data showed normal chemistry and blood counts. Her liver tests disclosed ALP 128 U/L, AST 1,348 U/L, ALT 1003 U/L, total bilirubin 8.2 mg/dL, direct bilirubin 6.4 mg/dL and INR 1.4 consistent with acute hepatitis. Infectious workup was positive for HCV genotype 1b with a viral load of 27.2 M IU/mL. Ultrasound of the abdomen showed normal liver and biliary tree. Immunological workup was positive for anti-smooth muscle antibody 1:40 titer and elevated IgG at 2,070 mg/dL raising a concern for a concomitant autoimmune hepatitis (AIH). Patient's liver tests continued to climb and she had prolonged abdominal pain, so liver biopsy was performed. It showed moderate lobular lymphoplasmacytic and neutrophilic inflammation with marked hepatocellular injury and areas of hepatocyte loss consistent with active HCV hepatitis (Figures 1 and 2). She was then discharged and immediately started on sofosbuvir-ledipasvir and eventually achieved sustained virologic response. DISCUSSION: Acute HCV infection is usually transmitted via needle-stick injury or injection drug use. It is uncommon in elderly patients, however in nursing home residents, it is attributed to parenteral medications, hemodialysis and poor adherence to infection control measures. Our patient was from the community and it is not clear how she was exposed to HCV. Acute HCV hepatitis in elderly patients can be severe, occurring 2 to 26 weeks after exposure. Aminotransferases are often greater than 10 to 20 times normal; bilirubin may be elevated as well. Although HCV is known to induce AIH, the features of acute hepatitis can be mistaken for AIH. A biopsy aids in discerning these two entities with very different treatment strategies. Generally, a waiting period of 12 weeks is instituted to allow for spontaneous viral clearance, but immediate treatment can be initiated in cases of elderly patients with severe presentations.