From focal lesion to fat sparing: Unmasking Zieve's syndrome with clinical vigilance Free

Zieve's syndrome is a rare and often overlooked complication of alcohol misuse, likely under-recognized due to limited physician awareness. We present a unique case with an atypical and misleading clinical presentation that initially raised concern for a hepatic mass. Despite the diagnostic uncertainty, the astute clinical vigilance and thoughtful evaluation by the treating team led to the correct diagnosis of Zieve's syndrome. This case highlights the importance of maintaining a broad differential and considering alcohol-related syndromes even when initial findings suggest alternative etiologies.

We present the case of a 29-year-old man with a history of essential tremor managed on propranolol, who was transferred for further evaluation of worsening jaundice following a brief, self-resolving viral-like illness. He denied abdominal pain, ongoing gastrointestinal symptoms, intravenous drug use, or alcohol intake.

Initial CT abdomen/pelvis showed hepatic steatosis and a 4.5 × 2.5 × 7.0 cm lobulated hypodense lesion in the right hepatic lobe, raising concern for pyogenic abscess versus neoplasm. Gallbladder wall was mildly thickened (5 mm) without pericholecystic fluid or biliary dilation. He was transferred for further evaluation. Laboratory evaluation revealed macrocytic anemia (Hb 9.9 g/dL, MCV 102 fL), thrombocytopenia (PLT 148), markedly elevated bilirubin (total 12.9 mg/dL, direct 6.8 mg/dL), transaminitis (ALT 93 U/L, AST 217 U/L), and evidence of hemolysis with low haptoglobin (30 mg/dL), elevated LDH (339 U/L), and a low reticulocyte count (0.39%). Sodium was 127 mmol/L, and INR was normal. Hepatitis viral panel, urine drug screen, and urinalysis were negative. Lipid panel revealed extreme hyperlipidemia with triglycerides 1500 mg/dL, LDL 687 mg/dL, and total cholesterol 1300 mg/dL.

Peripheral smear showed macrocytic anemia with mild anisocytosis, slight polychromasia, and mild red blood cell agglutination. RUQ ultrasound showed hepatic steatosis with no focal lesion. MRI liver protocol revealed hepatomegaly and diffuse hepatic steatosis with sparing in the falciform ligament, gallbladder fossa, and portions of the right hepatic lobe explaining the CT “lesion” as focal fat sparing rather than a true mass.

Although the patient denied alcohol misuse, phosphatidylethanol (PEth) testing was positive, confirming recent heavy alcohol consumption. The clinical picture was consistent with alcohol-associated liver injury, hemolysis, and secondary hyperlipidemia.

In conclusion, Zieve's syndrome is characterized by a triad of hemolytic anemia, cholestatic jaundice, and transient hyperlipidemia. Prompt recognition of this underdiagnosed condition is crucial, as it can prevent unnecessary invasive interventions and shift the clinical focus toward supportive care and alcohol cessation, which remains the cornerstone of treatment.