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March 3, 2020

Image challenge: dyspnea in hepatocellular carcinoma

What caused fatigue, dyspnea and abdominal pain in a patient innumerable lesions throughout his liver?
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Gastroenterology clinical image challenge: A 64-year-old man with untreated hepatitis B and C presented with fatigue, dyspnea and abdominal pain. He had a 1.7-cm hepatic lesion suspicious for hepatocellular carcinoma in 2011. He never followed up for further care until 2018, when he presented with abdominal discomfort. Magnetic resonance imaging of the liver revealed findings consistent with multifocal hepatocellular carcinoma. He was not interested in systemic chemotherapy and did not return until he developed fatigue and dyspnea with hypoxia requiring 6 L of oxygen support via nasal cannula in 2019. A chest radiograph at that time revealed extensive pulmonary nodules. A computed tomography scan revealed innumerable lesions throughout his liver, enlarged periportal and periaortic lymph nodes, and extensive pulmonary nodules (figure). Alpha-fetoprotein was 1470 ng/mL.

What is the most likely diagnosis causing this patient’s dyspnea?

To find out the diagnosis, read the full case in Gastroenterology.

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