Can't figure out the diagnosis

[maia]

hi!
can anybody help me with this?
A diabetic, 67 yrs old, male, without regular oral hypoglycemics came in for body malaise X 3 mos. icteric, afebrile.

CBC: Hgb=7 gm; WBC= 7,000/cumm; Hct=21 vol%.

CT scan & ultrasound of liver: has mass (but not described)
Total bilirubin=8 mg
Alpha fetoprotein = 4-6 mg
HbSAg=neg

CEA & PSA results=not in

Brother has history of hepatoma.

Uh, by the way, in case anyone's wondering why I'm asking this, I'm not an MD... and my friend who's in Internal medicine, gave me this for fun during the Xmas break...it's a bet between us. so i gotta win this
thanks

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[tricophyton]

That is an interesting question,
Someone anemic at that age makes you think of colon cancer
something was noticed at the liver which could be Mets. Mets can cause increase levels of AFP..... and the brother with the adenoma could just be a distraction .

However....
AFP levels in this case are way too high. Harrison's states that high levels of AFP (>1mg) with evidence of liver disease without obvious GI Cancer is strongly suggestive of hepatocellular CA (HCC). Again, harrison's does not mention any familial types.


Finally,
it could be Hereditary Hemochromatosis. That would explain the brother's involvement. HH often goes unrecognized. It can cause HCC, explaining the markedly elevated AFP. HCC causes anemia. See this article:
http://www.ccjm.org/pdffiles/mccarthy302.pdf

Well, I am not confident on any of my answers. It is an intriguing question.
Please share the answer when it becomes available.

 

[tricophyton]

one more thing I forgot to post above about HH is that it often causes diabetes which fits this patient

 

[amimigut]

No BUN/Cr data, w/o meds for DM, anemia could be secondary to diabetic nephropathy. However, no MCV, MCH though. It's hard to tell at this age group. For such a high AFP, colon CA is not likely. I will go for HCC origin. Also, we usually see lesions on the liver for mets, but not a big mass. I wouldnt think of mets in this case. In real life, I actually would repeat AFP (I have seen a lot lab errors on AFP), also there is no AST ALT number. The level of AST ALT could generate a D.D. For hepatoma, AFP usually would not go that high. Patient with such a high AFP would have cirrhosis, jaundice, ascites etc. CT should be able to pick it up.
Could be Pancreatic ca also, with such a high bili, and a big mass in the liver.

 

[Idiopathic]

Assuming AFP is correct, shouldnt it be a slam-dunk HCC though? I would second hemochromatosis as the precursor, given the diabetic 'not on oral hypoglycemics' (these are type I diabetics).

 

[AJM]

Assuming AFP is correct, shouldnt it be a slam-dunk HCC though? I would second hemochromatosis as the precursor, given the diabetic 'not on oral hypoglycemics' (these are type I diabetics).

Just because someone is diabetic and not on oral antihyerglycemics, it does not mean that they are type 1 diabetics. The writer in all likelihood meant that the patient has diet-controlled diabetes (type 2). If it was type 1, the writer would have specified insulin-dependent, and the patient would not be 67 years old. If he really has DM type 1 at the age of 67, that would have meant that he would have been diagnosed with DM type 1 about 60 years ago, when the life expectancy for these patients was very short.

Anyway, I'm not going to add my 2 cents in to this case, because I get the feeling that your friend wanted you to try to figure this out on your own as a kind of "challenge", rather than just turning around and asking other physicians/med students. (besides, there's probably good money involved in this bet - you should try to win it the fair way!)
Good luck!

 

[tricophyton]

Just because someone is diabetic and not on oral antihyerglycemics, it does not mean that they are type 1 diabetics. The writer in all likelihood meant that the patient has diet-controlled diabetes (type 2). If it was type 1, the writer would have specified insulin-dependent, and the patient would not be 67 years old. If he really has DM type 1 at the age of 67, that would have meant that he would have been diagnosed with DM type 1 about 60 years ago, when the life expectancy for these patients was very short.

Anyway, I'm not going to add my 2 cents in to this case, because I get the feeling that your friend wanted you to try to figure this out on your own as a kind of "challenge", rather than just turning around and asking other physicians/med students. (besides, there's probably good money involved in this bet - you should try to win it the fair way!)
Good luck!

I disagree with this post, I am glad that you asked this question. First of all this is not a question that you can just figure out on your own. There is nothing that is entirely specific for one condition. Hemochromatosis may be stretching it because it is missing several other things that would be expected. As for the diabetes, hemochromatosis is not the same as having Type 1 diabetes. It does cause insulin deficiency not insulin resistance therefore it is similar to type1.

I do agree with the above post in that just saying "not on oral hypoglycemics" does not give us enough info but probably means diet controlled.

The more I think about this question, I would say this is hepatocellular carcinoma. Elevated AFP to that level, and findings with U/S and CT it has to be as idiopathic already stated.

Again, thanks for asking the question, I am sure that Maia did look this up on his/her own before asking us.

 

[maia]

I am glad that you asked this question. First of all this is not a question that you can just figure out on your own. There is nothing that is entirely specific for one condition. Hemochromatosis may be stretching it because it is missing several other things that would be expected. As for the diabetes, hemochromatosis is not the same as having Type 1 diabetes. It does cause insulin deficiency not insulin resistance therefore it is similar to type1.

I do agree with the above post in that just saying "not on oral hypoglycemics" does not give us enough info but probably means diet controlled.

Again, thanks for asking the question, I am sure that Maia did look this up on his/her own before asking us.

hi!
thanks for the suggestions..by the way, the jury's still out on the dx. The pt currently has fever, but bilirubin levels have gone down. Will check on hemachromatosis. I also tried suggesting colon CA (considering the anemia and age) but it was not strong enough. The attending and a colleague have ruled out that it's mets from another site. I'll try to check on the missing labs amigut suggested.
re: diabetes, he's probably type 2 and probably not controlled too (diet) until he was admitted.
IN case, anyone would wonder why not taking oral hypogs and not 'controlled', people in our country (Phils.) even if they are diagnosed with any chronic condition, cannot take take drugs simply bec. they can't afford it and gov't won't pay. Same goes for lab tests, if possible, do the most definitive ones.
And AJM,
I'm not a doc nor medstudent. I'm in my last sem of BSN. I'm just 'on' this case bec my friend (who's also my Mom, who's the attending... ) wanted me to think...so, uh, either way, I'm gonna get a prize although that's not my motivation.
Really, THANKS a lot, this will really help the man. I will try to update you on the condition.

 

[Idiopathic]

My only point about Type I DM was that Px with Hereditary Hemochromatosis develop classic 'bronze diabetes'. The diabetes is of the Type I variety.