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Case Report: Pyrrolizidine alkaloid-induced hepatic sinusoidal obstruction syndrome misdiagnosed as ovarian malignancy

Year: 2026

Type: article

Abstract: Background Hepatic Sinusoidal Obstruction Syndrome (HSOS), formerly known as Hepatic Veno-Occlusive Disease (HVOD), is a rare and life-threatening liver condition. It is often caused by the ingestion of pyrrolizidine alkaloids (PAs), which are found in plants such as Gynura segetum (Tusanqi). Because its clinical presentation is non-specific, HSOS is frequently misdiagnosed. Case Presentation A 72-year-old female with a 5-year history of type 2 diabetes presented with abdominal distension and anorexia for 2 weeks. Initial examinations revealed massive ascites and significantly elevated tumor markers (Cancer Antigen 125(CA125): 195.0 U/mL, Human Epididymis Protein 4(HE4): 120.1 pmol/L). Imaging suggested potential ovarian cancer, leading to diagnostic laparoscopy and bilateral adnexectomy. However, intraoperative findings and post-operative pathology showed no evidence of malignancy, identifying only a serous cystadenoma. Subsequent detailed history-taking revealed long-term ingestion of “Tusanqi.” Re-evaluation via contrast-enhanced CT and MRCP showed characteristic patterns: patchy enhancement of hepatic parenchyma (“geographic” pattern), narrow hepatic veins, and signs of portal hypertension. The patient was finally diagnosed with PA-induced HSOS. Following a regimen of anticoagulation (low-molecular-weight heparin), liver protection, and diuretics, the patient’s abdominal distension relieved, and liver function markers showed partial recovery. The patient underwent laparoscopic bilateral adnexectomy due to a high suspicion of ovarian cancer, but the postoperative pathology ruled out malignant tumors, resulting in unnecessary surgical trauma. This article aims to improve the warning effect. Conclusion This case highlights the clinical challenge of distinguishing HSOS from abdominal malignancies. A thorough dietary/herbal history and characteristic “geographic” enhancement on imaging are pivotal for avoiding unnecessary surgical interventions.

Source: Frontiers in Pharmacology

DOI: 10.3389/fphar.2026.1833645