Loyola University Medical Center Oak Park, IL, United States
Saba Farooq, MD1, Michael Fayad, DO2, Jamie Berkes, MD2 1Loyola University Medical Center, Oak Park, IL; 2Loyola University Medical Center, Maywood, IL
Introduction: We are reporting a case of COVID infection and JAK2 V617F mutation causing acute portal vein thrombosis (PVT) and marked atrophy of the Right Hepatic Lobe (RHL).
Case Description/Methods: A 58-year-old female with a history of HLD who had recently tested positive for COVID presented to the ED with two days of shortness of breath and right sided pleuritic chest pain. Admission vitals were T: 99 F, BP: 137/68, P: 115, RR: 28, and saturation of 96% on RA. CTA chest was significant for bilateral pulmonary emboli and a new large low-density lesion within the R hepatic lobe. Labs were significant for troponin: 0.45 and d-dimer: 2572. CBC, BMP and liver enzymes were within normal limits. The patient was admitted and started on a heparin gtt. Her hospital course was relatively unremarkable, the tachycardia resolved and troponin levels normalized. She was discharged home on therapeutic apixaban with a plan to treat for 3 months for a COVID-provoked PE. As an outpatient, CT A/P with contrast was obtained and revealed posterior segments of the right hepatic lobe had undergone marked atrophy with compensatory left lobe hypertrophy. Occlusion of the R portal vein (PV) was observed with patency of the rest of the hepatic vasculature including arteries. Due to the interval liver anatomical alterations, the gallbladder had flipped and was now posteriorly oriented, which is what was previously mistaken for a new low density liver lesion on CTA. On f/u labs and extensive hematological evaluation, patient was found to have thrombocytosis (PLT: 406) and positive for JAK2 V617F mutation. Pt was started on prolonged anticoagulation per hematology. Patient evolved favorably with progressive clinical improvement.
Discussion: Atrophy of hepatic lobes associated with PVT in general and particularly right hepatic lobe PVT is rare and few cases are reported in literature. This case demonstrates an unusual presentation of RHL atrophy secondary to Rt PVT in the setting of a COVID infection and JAK2 V617F mutation. While exact mechanism not fully understood, hypercoagulability seen in patients with COVID has been well documented. In this case, although the etiology of the thromboses was suspected to be COVID induced hypercoagulable state, pt was sent to hematology per standard protocol to r/o other etiologies and that led to finding of JAK2V617F mutation. This was message to learn as it led to change in management of thrombosis with extension of anticoagulative therapy.
Figure: Right lobe atrophy and posteriorly orientated gall bladder (red arrow) read as a liver mass
Disclosures: Saba Farooq indicated no relevant financial relationships. Michael Fayad indicated no relevant financial relationships. Jamie Berkes indicated no relevant financial relationships.
Saba Farooq, MD1, Michael Fayad, DO2, Jamie Berkes, MD2. P2869 - COVID and Liver Mass: A Diagnostic Dilemma, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.
