Budd - Chiari Syndrome (BCS) is an uncommon hepatic vascular disorder affecting approximately 1 in every 2.5 million people worldwide often presenting as a sub - acute to chronic hepatic failure. Primary BCS, an even rarer subset of BCS, is described as the presence of intrinsic hepatic venous compression and occurs in 1 in every 6 million population. Primary BCS has often been attributed to hematologic disorders, more commonly myeloproliferative disorders, such as Polycythemia Vera, and in fewer cases, inherited thrombophilias, such as Protein C (PC) and Protein S (PS) deficiency, of which such cases are noted to be exceedingly rare. The authors describe a case of a 23-year-old Filipino female who was admitted on multiple occasions at a tertiary private hospital for over the course of a year, initially for complaints of epigastric pain and increasing abdominal girth. A review of the patient's past medical history was largely unremarkable with no familial cancers nor hepatitis infections noted, with the absence of oral contraceptive use. Initial workup consisted of serum chemistries and serology which yielded non specific and unremarkable findings. A series of imaging studies were then conducted - an initial screening abdominal ultrasound revealed an unremarkable biliary system and non specific structural hepatic parenchymal changes. A biopsy of the liver was taken revealing non specific venous congestion. The patient was then subjected to serial abdominal CT scans over the course of 6 months, which finally revealed complete absence of opacification of hepatic veins with a pattern suspicious for the presence of a thrombus, further mottled enhancement of the liver and splenic parenchyma due to congestion, all of which werefindings compatible with a Budd - Chiari Syndrome. Referral to a hematologist was carried out with thrombophilia workup done revealing decreased Protein C (Results: 32.2%,[Ref. Range: 70-140%]) and decreased Protein S (Results: 56%[Ref. Range: 60-140%]) results. The patient was then appraised of the eventual need for hepatic transplantation with a DIPS procedure contemplated.However, the patient eventually died from complications. This clinical case report documents an ethnic Filipino patient diagnosed with Primary BCS secondary to combined PC and PS deficiency, a subset of BCS that is both extremely rare and is not known to have previously occured in this population group. The authors cite this case to highlight both the need for diagnostic suspicion in cases of fulminant hepatic failure in the young and intend for it to be an early contribution to potential population based studies on BCS.Figure 1Figure 2