From the Department of Gasfroenterology, S.K. Institute of Medical Sciences, Soura, Srinagar, Kashmir, India.
Reprint requests: Dr. Gul Javid, Assistant Professor and Head, Department of Gastroenterology, Gulistan Manzil, Amira Kadal 190 001,
Srinagar, Kashmir, India
Manuscript Received: February 24, 1998; Initial review completed: March 24, 1998;
Revision Accepted: June 22, 1998
Primary liver cancer is uncommon in children in western countries accounting for approximately 1.1% of the total child- hood
cancer(1). It has a varied clinical presentation but commonly presents with
abdominal distention and mass in the right upper abdomen(2). We report a case of hepatocellular carcinoma in a 12-year-old boy mimicking liver abscess.
A 12-year-old boy was admitted with 15
of high grade intermittent
fever and pain in the right upper quadrant of abdomen. General physical examination revealed fever (100"F), right lower inter-costal tenderness and hepatomegaly (2
cm below the right costal margin). Investigations revealed normal hemoglobin, WBC count of 14000/cu mm. (polymorphs 75%, lymphocytes 23% and eosinophils 2%), normal kidney function tests, serum bilirubin 0.52 mg/dl (normal 0.2-1.10), serum alanine aminostransferase 90 IU /L (normal 0-37), aspartate aminotransferase 86 IU /L (normal 0-40), alkaline phosphatase 400 IU /L (normal 70-279), serum total proteins 6.0 g/ dl (normal 6.0-8.50), and serum albumin 3.0g/ dl (normal 3.5-5.0). Hydatid and amebic serology were negative. Chest roentgenogram was normal. Blood cultures were sterile. Ultasonography of abdomen revealed an enlarged fiver with 5 sq
cm area of altered echopattern in the right lobe.
The patient was treated as pyogenic liver abscess and received intravenous ciprofloxacin 200 mg twice daily and metronidazole 300 mg thrice daily but showed no improvement. Repeat ultrasonography revealed the same lesion on fifth day and ultrasonographic guided aspiration of the lesion was attempted. However, no material was obtained. On the sixth day, the patient was subjected to laparatomy to drain the abscess. At laparatomy,
the liver was found to be enlarged containing loculated abscess in the right lobe. Rest of the liver surface was nor- mal. Adhesions were present between the liver and anterior abdominal wall at the site of abscess. The abscess was drained and contained thick cheesy material which was sterile on culture and did not reveal any organism on Gram's and ZN stained
smears. Biopsy was taken from the abscess wall.
After surgery, the patient continued to have high grade fever, developed hypotension and cardiopulmonary arrest two days after surgery. Autopsy could not be done and the exact cause of death was not established.
The biopsy report available after the death of the patient revealed large polyhedral cells arranged in the form of trabeculae and some in acinii. Cells showed nuclear pleomorphism with frequent mitosis. The cytoplasm was vacuolated (Fig. 1). These features were suggestive of hepatocellular carcinoma.
Hepatocellular carcinoma (HCC) is a relatively rare tumor in young individuals and constitutes 0.7% of malignant hepatic tumors in children(3).
Abdominal distension and right upper quadrant mass are the most common presentations of hepatocellular
carcinoma(2). In a series of 71 pediatric patients, 97% presented with hepatomegaly, 42% with splenomegaly, 25% with ascites, 23% with superficial venous engorgement, 18% with jaundice and 14% with lymphadenopathy. Abdominal mass was presenting feature in 40.8%, abdominal pain in 38.1%, anorexia, malaise and fever were presenting symptoms in 12.7%, 9.9% and 7% patients respectively(4). A review of 32 cases of childhood and adolescent hepatocellular carcinoma
reported abdominal mass as presenting complaint in 30 patients, abdominal pain in 14 cases, weight loss/anorexia in 12 subjects and icterus and fever in 6 patients. Eight patients had a recognizable underlying or associated abnormality while 5 had underlying cirrhosis(5).
Fig. 1. Microphotograph showing features of hepatocellular carcinoma (H&E stain 20x).
Fever which is an uncommon presentation of HCC may be the ,manifestation of the
malignancy itself or due to the secondary infection of the tumor. High grade fever and leukocytosis has been described in poorly differentiated HCC(6) and the clinical picture may be exactly that of liver abscess(7,8). At times it becomes difficult to differentiate an abscess from HCC even with ultrasonography(9).
Patients have been described with pyogenic liver abscesses which occured in association with hepatic tumor nodules. Intrahepatic metastatic deposits complicated by pyogenic abscesses have been reported in seven patients and Actinomyces israeli was isolated from one case(10).
Since our patient had no evidence of extra-hepatic focus of infection and no
organism could be demonstrated on smear and culture of aspirate, we feel the fever and leukocytosis
may be the manifestation of the tumor itself rather than due to pyogenic process in the tumor.
In conclusion, in our clinical set-up, in any young patient presenting with
clinical features of liver abscess without any extrahepatic focus of infection
even without underlying liver disease, hepato-cellular car-cinoma should be considered. Various tumor specific isoenzymes, tumor markers and fetal antigens should be estimated, besides, hepatitis B and hepatitis C viral
status. Ultrasound guided aspiration of the liver lesion should be attempted for culture and histopathological examination of the aspirates, to establish the diagnosis or a biopsy should be taken from the abscess wall if the patient needs surgical drainage of the abscess.
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