Nutmeg liver, fever and elevated liver enzymes in a young man

Question

A 27-year-old man was admitted to our department because of persistent symptoms of fever, dyspnoea, dry cough, elevated C reactive protein (CRP) (258 mg/L), leucocytosis (17x10⁹/L), peripheral eosinophilia (29%) and elevated liver enzymes (alanine aminotransferase (ALT) 518.2 U/L; aspartate aminotransferase (AST) 192.4 U/L; total bilirubin 1.6 mg/dL direct bilirubin 0.7 mg/dL; alkaline phosphatase 115.9 U/L and gamma glutamyl transferase (GGT) 119,4 U/L). His medical history was unremarkable except for surgery that he underwent 3 weeks ago for his left radius and ulna fracture. Since the surgery, he has been taking paracetamol and sodium metamizole. Empirical antibiotic therapy was initiated.

Chest X-ray revealed small left and large right pleural effusion. CT was performed due to elevated D-dimer, and there were no signs of pulmonary embolism. Right pleural effusion was drained, the microbiological analysis of pleural fluid was negative. Abdominal CT showed hepatomegaly with inhomogeneous mottled liver parenchyma consistent with features of 'nutmeg liver'. In addition, hepatic veins were not identified,...

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