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A 61-year-old male is admitted to the internal medicine ward for evaluation of weight loss and an increase in abdominal girth.

He is the father of an African student who is currently studying in the United States. His son brought him here from Central Africa for treatment of his disease.

Thin, emaciated male; marked jaundice; abdomen markedly enlarged due to ascitic fluid; hepatomegaly; pitting edema in both lower legs. ยง

CBC: anemia (Hb 6.3) (sometimes there may be polycythemia due to ectopic erythropoietin secretion). Increased a-fetoprotein; hypoglycemia (due to increased glycogen storage); AST and ALT elevated; alkaline phosphatase elevated.

US/CT, abdomen: enlargement of liver with multiple nodularities involving the vena cava; enlargement of regional lymph nodes.

Liver biopsy confirms clinical diagnosis, showing fibrotic changes and glycogen accumulation with vacuolation and multinucleated giant cells; pleomorphic hepatocytes seen in a trabecular pattern (may also be adenoid or anaplastic) with malignant change (hepatocellular carcinoma).

Palliative.

Hepatocellular carcinoma is frequently seen in association with hepatitis B virus infections and with cirrhosis. There is a dramatic predisposition to this neoplasia in Africa and in parts of Asia; it is the most common visceral neoplasm in African men. Causative theories include the carcinogenic action of anatoxins on genetically susceptible individuals. Anatoxins are produced by the contamination of peanuts and improperly stored grains (staple food in many African countries) with the fungus Aspergillus favus.

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