Portal Venous Thrombosis: Eosinophilic Vasculitis

A 48-year-old male presented to medicine outpatient department with abdominal distension of one month duration, which was progressive and worsened in the last one week.He did not take any treatment at this stage.There was also history of fever with thrombocytopenia (which was documented in the previous blood investigation report) one week back and treated conservatively for the same.There was no history of any bleeding manifestations.The patient also complained of weight loss which was not quantifiable, associated with decreased appetite for last one month.He used to take alcohol for last 10 years occasionally but never smoked.On examination, his vitals were stable.Abdomen examination showed diffuse distension of the abdomen with free fluid and there were dilated veins over the abdominal wall.Rectal examination was normal.Respiratory system examination showed bilateral occasional rhonchi.Other system examination was normal.His blood investigation revealed eosinophilia and thrombocytopenia.Total count-18,100 cells/cumm with neutrophils-46%, lymphocytes-18%, eosinophils-35%, platelets-13000 cells/cumm, absolute eosinophil count-6330/µl, ESR-10 mm/hr, IgE (ELISA)-312 (normal-2.0-305.9IU/ml).Diagnostic ascitic fluid tapping was done, which showed eosinophilic ascitis with a total count of 270 cells, differential count of polymorphs 12%, lymphocytes 60%, eosinophils 28%.Serum Ascitis Albumin Gradient (SAAG) was high, suggestive of portal hypertension.Liver function test showed elevated liver enzymes (SGOT-407 u/l, SGPT-1250 u/l).Hepatitis B and C virus serology was negative.Prothrombin time-Patient/ Control-17.9/11.5,INR was 1.5.X-ray chest was normal.A 2D echo cardiography showed normal left ventricular function.Ultrasound of the abdomen showed moderate ascitis, minimal right-sided pleural effusion with the suspicion of PVT.He then underwent Computed Tomography (CT) of abdomen with contrast, which showed portal vein [Table/Fig-1], superior mesenteric vein thrombosis [Table/Fig- 2].CT thorax showed thrombosis involving right lower territory of pulmonary vein.With this presentation of peripheral eosinophilia, eosinophilic ascitis and venous thrombosis, we considered eosinophilic granulomatosis with polyangitis-Churg-Strauss disease.His vasculitic work up c ANCA, p ANCA, ANA (ELISA, Indirect Immunofluorescence) including anti phospholipid antibody were negative with normal complements.Serum homocysteine level was normal.As we suspected CSS, retrospectively we confirmed the history of allergy to dust and fumes

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