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Clinical History:

A 29 year-old previously healthy female presented with sub-acute symptoms of weight loss, right upper quadrant pain and nausea.

CBC results: WBC-11.7, Hb- 12.5, Platelet- 286, MCV- 90, MCV- 26.8, RDW- 18%.

Imaging: Ultrasound and MRI of the abdomen were suggestive of Budd-Chiari syndrome that was supported by a liver biopsy showing features of hepatic outflow obstruction(Figure 1). There was no clinical or radiological evidence of splenomegaly. The hypercoagulable work-up was negative. An underlying Myeloproliferative Neoplasm (MPN) was suspected.