Polymyositis Associated with Hepatitis B Virus Cirrhosis and Advanced Hepatocellular Carcinoma

Paraneoplastic syndromes in hepatocellular carcinoma: a review

INTRODUCTION

Hepatocellular carcinoma (HCC) is one of the most common cancers worldwide, and a significant proportion (20-40%) of patients with HCC develop paraneoplastic syndromes (PNS). Despite this, there is a paucity of clinical evidence regarding PNS in HCC.

AREAS COVERED

A systematic search was performed to identify relevant case studies regarding PNS in HCC. Another search was conducted to identify studies that evaluated the impact of PNS on survival outcomes in HCC. Since there are currently no international guidelines for PNS in HCC, this review aims to provide comprehensive summaries and recommendations of PNS in HCC, including the pathophysiology, clinical features, diagnostic approach, and management, so that clinicians remain guided in caring for HCC patients with PNS. In general, PNS are associated with poorer survival outcomes and negative prognostic markers of HCC.

EXPERT OPINION

The presence of PNS has a significant influence on survival rates and clinical outcomes of patients with HCC. They contribute to significant morbidity, influencing patients' quality of life and fitness for curative and palliative therapies. Therefore, it is paramount for PNS to be integrated into routine investigations after diagnosing HCC to guide further management and prognostication of the disease.

Association of acute hepatitis B and acute myopathy: a case report

BACKGROUND

Hepatitis B virus infection is a global public health problem. Although hepatitis B virus primarily affects hepatocytes, it sometimes develops disease manifestations outside the liver, such as myopathy, which is commonly caused by chronic hepatitis B.

CASE PRESENTATION

This case report describes a 57-year-old Iranian woman admitted to the hospital with jaundice, fever, body itching, abdominal pain, progressive muscle weakness, icteric sclera, right upper quadrant pain, and decreased muscle force. Examination on the first day of admission revealed that the patient was negative for hepatitis D antibody, positive for hepatitis B core (IgM) antibody, positive for hepatitis B surface antigen, and negative for hepatitis B e antibody but positive for hepatitis B e antigen. Moreover, she showed high levels of hepatitis B virus DNA viral load, creatine kinase, lactate dehydrogenase, serum glutamic-oxaloacetic transaminase, serum glutamic-pyruvic transaminase, total bilirubin, direct bilirubin, and alkaline phosphatase, and electromyography/nerve conduction velocity showed acute myopathic process.

CONCLUSIONS

Interestingly, myopathy symptoms improved after improving hepatitis symptoms and decreasing hepatitis B viral load, suggesting a close association between hepatitis B infection and myopathy.

Elevation in creatine kinase isoenzyme-MM associated with hepatocellular carcinoma: a case report and review of literature

We report the case of a 79-year-old woman with hepatocellular carcinoma (HCC) who presented with creatine kinase (CK)-MM elevation. On admission, her serum CK-MM level exceeded 4000 IU/L (normal, 44-206 IU/L), and computed tomography revealed two HCCs in hepatic segment VIII (23 mm, 86 mm). The patient denied experiencing muscular symptoms such as weakness or pain. Hypothyroidism, ischemic heart disease, muscular dystrophy, autoimmune myopathy, drug-induced rhabdomyolysis, and paraneoplastic inflammatory myositis syndrome (PIMS) were included in the differential diagnosis for high CK-MM, but none were suspected. Although the cause of elevated CK-MM was not elucidated, an HCC-related mechanism was considered and the tumor was resected. The CK-MM levels declined gradually to 300 IU/L postoperatively without any special perioperative management. Nineteen cases of HCC-associated CK-MM elevation have been reported in English thus far, in all of which, inflammatory myositis was concluded as the cause of CK-MM elevation. However, in this case, the elevation of CK-MM was associated with HCC-related mechanisms distinct from PIMS, suggesting HCC-related mechanisms should not be excluded as a cause of high CK-MM, even though PIMS is negative.

Severe digital ischemia coexists with thrombocytopenia in malignancy-associated antiphospholipid syndrome: A case report and review of literature

BACKGROUND

Paraneoplastic syndromes are characterized by atypical clinical manifestations. Several reports of hepatocellular carcinoma (HCC) paraneoplastic phenomena have been reported. They usually manifest as one type in an individual, but it is not common for the two clinical manifestations to occur simultaneously.

CASE SUMMARY

A 52-year-old female patient was admitted to hospital with pale skin and numbness of the second to fifth fingers in the left hand, which rapidly developed into severe digital ischemia. Computed tomography angiography revealed uneven thickness of the left ulnar artery with severe local luminal stenosis. Blood analysis during hospitalization showed persistent mild to medium thrombocytopenia and insensitive to hormonal therapy. Antiphospholipid antibody testing showed high titer of IgG anticardiolipin antibodies (aCLs), IgA aCLs, IgG anti-β2-glycoprotein-I (anti-β2 GPI), and IgA anti-β2 GPI. The exact diagnosis was HCC when the high a-fetoprotein levels, computed tomography findings, and the history of chronic hepatitis B came together. This was a rare case of coexisting manifestations as presenting symptoms of malignancy-associated antiphospholipid syndrome. The patient underwent several operations, antithrombotic treatments and hormonal therapy. However, the patient refused chemotherapy and died 8 wk after diagnosis.

CONCLUSION

This report highlights the importance of atypical clinical changes that could alert the physicians to vigilance for a concomitant underlying malignancy.

Polymyositis and rhabdomyolysis caused by hepatocellular carcinoma - Case report and literature review

Introduction

Rhabdomyolysis is a syndrome characterized by a rapid necrosis of muscle fibers and the release of muscle-derived metabolic products into the circulatory system. A rare cause of rhabdomyolysis is paraneoplastic polymyositis.

Case presentation

A 67-year-old man was diagnosed with paraneoplastic polymyositis and rhabdomyolysis caused by hepatocellular carcinoma (HCC). Intravenous steroid was used as a symptomatic therapy for rhabdomyolysis, and the tumour was removed by left hemihepatectomy to treat the underlying cause. After muscle strength gradually improved, steroid therapy was discontinued. The patient was reoperated multiple times due to bleeding and bile leakage. Following the operations, his overall state and muscle strength further improved. Despite that, the patient's condition worsened again, and eventually, he died of candida albicans pneumonia and sepsis.

Discussion

HCC is an extremely rare cause of paraneoplastic polymyositis and rhabdomyolysis. Treatment is challenging, as none of the few available case reports record long term survival and less than half of the reports record muscle strength improvement. In our case, the patient was treated with systemic steroid therapy and resection of the tumour. The patient's muscle strength temporarily improved, but subsequently, the patient died.

Conclusion

Our case confirms the importance of a definitive treatment of HCC, as we achieved a significant improvement in muscle strength by removing the tumour. On the other hand, our paper highlights the dangers of double-sided steroid therapy, which, combined with the essential, effective treatment of rhabdomyolysis, may have contributed to the development of postoperative complications and candida sepsis leading to death.

Dermatomyositis Induced by Hepatitis B Virus-related Hepatocellular Carcinoma: A Case Report and Review of the Literature

Dermatomyositis or polymyositis as a paraneoplastic syndrome of hepatocellular carcinoma (HCC) is an uncommon event. Few cases have been reported in the literature. We herein report the case of a 55-year-old man with chronic hepatitis B and alcoholism who presented with skin rash. Abdominal computed tomography revealed multiple hypervascular liver tumors consistent with HCC. He subsequently developed dysphagia with proximal limb weakness. Laboratory tests and electromyography demonstrated inflammatory myopathy. We therefore diagnosed the patient with HCC-induced dermatomyositis. Prednisolone and anti-viral therapy were administered; however, the patient died two months later due to the progression of the disease. We review the cases of HCC-induced dermatomyositis and polymyositis in the literature.