A rare vascular puzzle: Portal hypertension and hepatic lesions

A 51-year-old woman presented to an external hospital with lower leg edema and abdominal distension in March 2023.Her BMI was 27 kg/m 2 .She reported no significant prior alcohol consumption.On examination, leg edema was confirmed, and ascites was suspected.Laboratory tests showed minimal increase in alanine aminotransferase and gamma-glutamyltransferase, with mildly altered liver function (bilirubin, albumin, and international normalized ratio).Abdominal ultrasound revealed hepatomegaly and partial portal vein thrombosis.A hyperechoic, inhomogeneous liver lesion was detected.Subsequent CT and MRI scans showed three nodular-cystic lesions (20-23 mm) in segments VI, VII, and II with contrast enhancement but no portal venous phase washout, leading initially to a suspicion of atypical hemangiomas.Additionally, ascites and collateral circulation consistent with portal hypertension were detected.Upper gastrointestinal endoscopy confirmed small esophageal varices and portal hypertensive gastropathy.The working diagnosis was fibrosis to cirrhosis with partial portal vein thrombosis and atypical hemangiomas.Treatment with beta blockers, oral anticoagulation, and diuretics was begun.After 3 months, the thrombosis had resolved.The lesions were stable in size but were increasingly cystic.By August 2023, progressive hepatomegaly with progressive contrast enhancement and an increased size of the liver lesions were noted.Laboratory tests showed elevated inflammatory markers.Blood cultures yielded Klebsiella species and Parvimonas micra, which led to suspicion of liver abscesses and initiation of antibiotic therapy.