A Case of a 32 Year Old Immunocompetent Female with a Portal Vein Thrombosis Secondary to Cytomegalovirus Hepatitis

Abstract

Purpose: The patient is a 32 year old female who presented with right upper quadrant abdominal pain, nausea and vomiting. Prior to presentation she had cough with fever and nausea for 2 weeks. She had been seen by her primary care physician who had put her on a course of azithromycin for a presumed bronchitis with no improvement. In the emergency department, the patient was found to have abnormal liver function tests with an aspartate aminotransferase level of 243, alanine aminotrasferase level of 478, and alkaline phosphatase level of 116 and total bilirubin level of 0.8. A CT scan of the abdomen and pelvis revealed a thrombus of the anterior segmental branch of the right portal vein. The patient denied any significant past medical history. She used ibuprofen on an as needed basis and was on an oral contraceptive pill. The patient was evaluated by hematology and underwent an extensive work-up for an underlying hypercoagulable state which was negative. The patient's only risk factor was felt to be the use or oral contraception. The patient was also evaluated by the infectious diseases team and underwent an extensive viral work up including viral hepatitis panel, EBV, HIV, Influenza A and B, RSV, Parvovirus, and CMV. The only positive test was CMV PCR. An ultrasound with doppler showed partially occlusive thrombus extending from the main portal vein into several braches of the anterior right portal vein. The patient was started on anticoaguation with a heparin drip transitioned to coumadin given concern of extension of the clot. Given a high viral load and the thrombus the patient was also started on valganciclovir for treatment of CMV hepatitis. A month after discharge the patient's liver function tests had returned to normal. Follow up ultrasounds have shown improvement in the thrombus. CMV hepatitis leads to local inflammation as well as systemic responses that can increase the risk of portal vein thrombosis. Patients with CMV hepatitis are at risk for forming portal vein clots especially when there are other underlying pro-coagulant risk factors. CMV should also be considered in cases of portal vein thrombosis without a known cause.