A liver mass in a cirrhotic liver should always raise the concern for hepatocellular carcinoma (HCC), and expert guidelines state that diagnosis can be made with imaging alone in some settings. Our case illustrates that care must be taken to consider other etiologies before making that diagnosis. A 57 year old man with alcoholic liver cirrhosis came to the ED complaining of 1 month of severe, intermittent abdominal pain with associated subjective fever and chills. A CT abdomen on admission reported 2 ill-defined hypodense liver lesions concerning for HCC. In the setting of liver cirrhosis and a hepatic mass, work up for HCC was initiated, including an AFP which was later found to be normal. IR was consulted for possible biopsy, however because the patient had an elevated INR and thrombocytopenia it was deferred and a triple phase MRI was instead recommended to further evaluation. Infection was initially lower on the differential due to lack of fever and normal WBC. On hospital day 2 one of the BCXs from admission revealed Streptococcus viridians (later updated to Strep milleri). On hospital day 3, fevers, tachycardia and leukocytosis developed. An abscess was now more likely. The patient was initially monitored without antibiotics, but after the positive culture and the episode of fever, he was started on ceftriaxone and a second set of BCX were drawn which later revealed the same organism. The MRI showed two rim enhancing lesions in the right hepatic lobe which in the setting of infectious symptoms, were favored to represent abscesses. ID was consulted and recommended 6 weeks of IV ceftriaxone. A TEE showed no evidence of endocarditis. A repeat CT showed the masses to be decreased in size and the patient was discharged with Clindamycin 300mg TID for an additional month. His last CT continued to show evidence of improvement and he was clinically improved as well, so clindamycin was discontinued and he was discharged from the Infectious Disease clinic. This case illustrates that caution must be used in making a presumptive diagnosis of HCC in a cirrhotic with a new liver mass. Other diagnostic tools such as serum markers (AFP), blood cultures and further imaging should be considered when biopsy is not an option and clinical features suggest alternative diagnoses.
Aguayo-Rico, Alberto and Jennifer Jernigan. "Clinical vignette: Pyogenic liver abscess vs. hepatocellular carcinoma, the challenge of diagnosis without a biopsy." (2014). https://digitalrepository.unm.edu/hostpitalmed_pubs/40