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Pylephlebitis, otherwise known as septic portal vein thrombosis, is an infective suppurative thrombosis of the portal vein and/or its intra-hepatic branches. It is a diagnosis that is frequently missed but easily treated with antibiotics. Therefore, it should be considered early on in any patient presenting with fever, abdominal pain, leukocytosis, and evidence of portal vein thrombosis on a CT scan. In this case report, we discuss a case of pylephlebitis as well as the etiologies, diagnosis, and treatment of septic portal vein thrombosis.

We present a case of refractory hypernatremia in a patient with elevated adrenocorticotropic hormone (ACTH) and hypercortisolism. Cortisol’s effect in tissues results in various outcomes, from maintaining blood pressure to increasing serum glucose levels. In addition, cortisol, cortisone, and aldosterone activate mineralocorticoid receptors with the same affinity; therefore, the activation of mineralocorticoid receptors by elevated cortisol levels leads to increased sodium reabsorption, increased potassium secretion, and metabolic alkalosis. Hypernatremia in our patient was initially refractory to fluid replacement but was eventually corrected with intravenous fluid and desmopressin. Overall, we suggest that hypercortisolism should be considered a differential diagnosis in hypernatremia refractory to fluids replacement.

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