Hepatocellular Carcinoma Presenting as ST Elevation in V1 and V2 (Brugada Pattern)

Abstract

Introduction: Hepatocellular carcinoma (HCC) is usually discovered on routine ultrasound screening in patients with chronic liver disease or when symptomatic enough to warrant investigation. However, initial presentation of HCC as ST—segment elevation in V1 and V2 (Brugada pattern) has never been previously reported. Case Presentation: We report a 63—year—old African American male with past medical history of hypertension, tobacco abuse, and schizophrenia, who presented with 3 weeks of right upper quadrant and epigastric abdominal pain, which was worse when bending over. EKG on admission showed new ST elevation in V1 and V2 with reciprocal changes in inferior leads when compared to previous EKG in June 2016, which was concerning for acute STEMI (Fig. 1). Cardiology was consulted, and the patient underwent cardiac catheterization, which was negative. Following negative cardiac catheterization, he was transferred back to the General Medicine service for workup of his abdominal pain. Abdominal ultrasound was negative for cholecystitis or stones. Due to continued symptoms he received a CT abdomen (Fig. 2), which showed a large mass in the left lobe of the liver, as well as gastric wall thickening and large left upper quadrant varices. The patient at this time acknowledged being diagnosed with hepatitis C infection more than 20 years ago. Gastroenterology was consulted, and the patient underwent EGD, MRCP, and colonoscopy. MRI (Fig. 3) showed 2 focal masses within the left lobe of the liver, findings concerning for infiltrative neoplastic process. Tumor markers, including AFP, CA19—9, and CEA, as well as hepatitis serologies were drawn. AFP was significantly elevated to approximately 10,000 ng/mL, and the diagnosis of hepatocellular carcinoma was considered highly likely. Initial read of triple—phase CT was atypical for hepatocellular carcinoma; therefore, liver biopsy was scheduled with Interventional Radiology. Final read of the CT showed left hepatic lobe mass with invasion and occlusion of the left portal vein, most consistent with hepatocellular carcinoma. Pathology from liver core biopsy was consistent with HCC.3025_A.tif Figure 1: EKG showing ST segment elevation in V1 and V2 (Brugada pattern)3025_B.tif Figure 2: CT abdomen showing a large mass in the left lobe of the liver3025_C.tif Figure 3: MRI abdomen showing 2 focal mass—like areas within medial segment of left lobe of the liverDiscussion: HCC is the ninth most commonly diagnosed cancer worldwide. HCC is usually discovered either during routine screening or when symptomatic. In our case, HCC was presented in a patient with acute epigastric pain and EKG findings of ST—segment elevation. This case shows that intra—abdominal tumors, such as HCC, may present as ST elevation.