Portal Vein Thrombosis and Hepatic Infarction as a Rare Complication of Disseminated Tuberculosis in Advanced HIV Disease: A Case Report From Mthatha Regional Hospital, South Africa

Portal vein thrombosis (PVT) is an uncommon yet potentially life-threatening vascular complication defined by partial or complete obstruction of portal venous flow.Active tuberculosis (TB) is increasingly recognised as a prothrombotic condition, with systemic inflammation, endothelial dysfunction, platelet activation, and alterations in natural anticoagulant pathways contributing to thrombus formation.The risk of PVT may be further increased in the context of advanced human immunodeficiency virus (HIV) infection.Nevertheless, reports of PVT associated with disseminated TB in patients with advanced HIV disease remain rare, particularly in high-burden, resource-limited settings.A 26-year-old woman with advanced HIV infection and poor adherence to antiretroviral therapy presented with progressive abdominal distension, abdominal pain, constitutional symptoms, jaundice, and massive ascites.Laboratory investigations revealed severe immunosuppression (CD4 count 45 cells/µL), pancytopenia, transaminitis, coagulopathy, and marked hypoalbuminaemia.GeneXpert testing of ascitic fluid and sputum confirmed rifampicin-sensitive Mycobacterium tuberculosis.Contrast-enhanced computed tomography identified extensive PVT involving the main and right portal veins, with collateral flow and wedge-shaped hypoattenuation of the right hepatic lobe, consistent with hepatic infarction.Additional findings included extensive abdominal lymphadenopathy and splenic lesions.Chest imaging showed miliary nodular infiltrates and left lower lobe consolidation, supporting a diagnosis of disseminated tuberculosis.The superior mesenteric vein and artery remained patent.The coexistence of advanced HIV infection and disseminated TB provides a plausible multifactorial basis for PVT, resulting from synergistic effects of persistent systemic inflammation, immune dysfunction, activation of endothelial and coagulation pathways, and local impairment of portal venous flow due to extensive tuberculous lymphadenopathy.Hepatic infarction is an uncommon complication of extensive PVT, given the liver's dual arterial and portal blood supply.Management of TB-associated PVT is particularly challenging in the presence of thrombocytopenia, coagulopathy, and advanced hepatic dysfunction, as these factors significantly increase bleeding risk and complicate anticoagulation decisions.PVT should be considered in patients with advanced HIV disease and disseminated TB who present with abdominal pain, ascites, or features of portal hypertension.This case demonstrates the rare association of disseminated TB with extensive PVT and hepatic infarction in advanced HIV disease, emphasising the interplay between systemic TB-associated inflammation, HIV-related prothrombotic mechanisms, and local vascular compromise.Early recognition, appropriate cross-sectional imaging, microbiological confirmation, and multidisciplinary assessment are critical for timely diagnosis and management of this potentially lifethreatening complication.