A rare cause of high liver stiffness

A 71-year-old man with a past medical history of arterial hypertension was referred to our outpatient clinic for a suspected liver disease, based on biochemical and radiological findings. He was poorly symptomatic with discrete weight loss due to reduced appetite. Physical examination revealed a good general condition, hepatosplenomegaly, overweight (BMI 27) and enhanced waist circumference. Biochemical examination showed pancytopenia (hemoglobin 11,4 g/dL [13.3-16.7 g/dL], white cells count 3870/μL [4-10x103/μL], platelets count 38000/μL[150-350x103/μL]) and cholestasis (gGT 147 U/L [<60U/L], alkaline phosphatase 152 U/L [40-130 U/L], total bilirubin 2.1 mg/dL [<1.2mg/dL]). ALT and AST levels were normal. The usual liver biochemical etiology tests were negative unless elevated type M immunoglobulins and an antinuclear antibody titer of 1/160. Doppler-abdominal ultrasonography showed a heterogeneous liver (Figure 1A), large splenomegaly (Figure 1B) and several enlarged lymph nodes. Liver vascularization was normal. Differential diagnosis included a chronic liver disease (seronegative primary biliary cholangitis, fatty liver disease or cardiac liver disease) and a hematological disorder infiltrating the liver. Median liver elasticity (E), evaluated by transient elastography (TE), was compatible with cirrhosis (22.8 kPa) while controlled attenuation parameter (CAP) evaluation suggested slight steatosis (Figure 1C). What do you recommend?