Hepatocellular carcinoma disguised as liver abscesses

The incidence of hepatocellular carcinoma (HCC) is growing rapidly in the United States. Nonalcoholic fatty liver disease and nonalcoholic steatohepatitis are being increasingly recognized as known risk factors for the development of HCC. However, this risk seems to be associated with their progression to cirrhosis. This case demonstrates an unusual initial presentation of HCC masquerading as liver abscesses in a previously healthy woman with nonalcoholic fatty liver disease without cirrhosis. Our patient's clinical presentation was suspicious for an infectious etiology due to her ongoing fever in the setting of possible zoonotic transmission, because she had just acquired two unvaccinated kittens. Abscess-like clinical presentation can be seen in HCC and is due to neoplasm-associated granulocytosis. Fever is due to pyrogen production by malignant tumor cells or by macrophages. Therefore, HCC can be difficult to differentiate from a hepatic abscess, and aspiration of malignant cells may be needed for an accurate diagnosis. Although the incidence of HCC in nonalcoholic fatty liver disease without cirrhosis is low or unknown, surveillance for HCC should be considered due to the higher prevalence of nonalcoholic fatty liver disease in the developed world and its potential risk for HCC.