A 29-year-old West African male presented to the hepatology clinic after testing positive for hepatitis B surface antigen (HBsAg) during routine screening. Positive HBsAg and negative HBsAb distinguished between infection and immunity. Further testing showed positive HBeAg, HBeAb, and HBcAb (IgG and IgM), HB viral load of 1,698,244 IU/mL, and normal liver enzymes, consistent with phase 1 chronic hepatitis B. Liver ultrasound (US) done to evaluate for cirrhosis and screen for hepatocellular carcinoma (HCC) showed neither pathology. Given the absence of cirrhosis and normal liver enzymes, he did not meet criteria for HBV infection treatment. He was instructed to follow-up with repeat LFTs (3–6 months), HBeAg (6–12 months), and liver US (6 months). He was also enrolled in an HCC surveillance program as he was high risk for HCC (HBV positive and older than 20 years with African ethnicity). He was, however, lost to follow-up.
Four years later, he presented with abdominal distension and 1 month of weight loss. Physical examination showed a distended and tense abdomen with elevated liver enzymes and HBV viral load. A CT scan showed innumerable hyper-enhancing masses in the liver (Fig. 1a, b, c), and an US-guided liver biopsy confirmed moderately differentiated HCC. The patient’s hospital course was complicated by hemoperitoneum, and ultimately he was transitioned to comfort care.
Figure 1.
Computerized tomography images with arrows. a Masses in the left lobe of liver (white arrows). b Hyper-enhancing masses in the right lobe of liver with central necrosis and distortion of the liver architecture (white arrows). c Dominant lesion (20×13×25 cm) with central necrosis, longest diameter shown by white line, lateral and medial borders shown by white arrows. Additional lesions extending into pelvis inferiorly (black arrows).
Our case highlights a key learning point for physicians regarding the importance of HCC surveillance in high-risk patients.
Declarations
Conflict of Interest
The authors declare that they do not have a conflict of interest.
Footnotes
Muhammad Hashim Hayat and Abdul Wahab contributed equally to this work.
SGIM Membership: Muhammad Hashim Hayat is a member of SGIM.
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