A 57-year-old Chinese man was brought to the emergency department for sudden loss of consciousness. Upon admission, his blood pressure was 160/97 mmHg, pulse was sinus at 124 beats/min. Blood sugar was 160 mg/dl. Neurologic examination showed absent doll’s-eye movement. Pupils were equal and reactive to light. There was no motor response in the face to supraorbital pressure. The upper limbs were extended to pain stimuli, and the lower limbs were flexed with Babinski signs. Other physical findings were normal. The clinical features were compatible with pontine infarct. CT and MRI of the brain and brainstem were normal.

Haemoglobin was 9.5 g/l. Serum sodium was 142 mmol/l, alkaline phosphatase was 437 IU/l (normal 53–128), alanine aminotransferase was 1047 IU/l (normal <38), bilirubin was 75 μmol/l (normal 2–23). Ammonia was 117 μmol/l (normal 16–60). Hepatitis B virus (HBV) surface antigen was positive. Alpha-fetoprotein (AFP) was over 7000 ng/ml. CT scan revealed a cirrhotic liver with a 12 cm right lobe lesion that resembled hepatocellular carcinoma (HCC). Pulmonary metastases were evident. The patient died one month later.

HCC is the fifth most common malignancy worldwide and often complicates chronic viral hepatitis or cirrhosis of any cause. There is convincing epidemiologic and molecular evidence to implicate HBV as a causative agent.1,2 As HBV infection is endemic in Southeast Asia, HCC is most prevalent in this locality.3 Atypical presentations often mask the diagnosis. We have previously reported sciatica as an initial presentation.4 To our knowledge, HCC manifesting as encephalopathy that mimics pontine infarct has not been reported before. The clinician needs to be aware of the wide spectrum of clinical presentation of HCC. Surveillance by AFP and/or ultrasonography in endemic areas and races can identify tumours at an early stage,5 which may increase the chance of cure.

Sydney Tang

Chin Pang Chan

Ping Wing Ng
Department of Medicine and Geriatrics
United Christian Hospital, Hong Kong