A Farmer With Diffuse Pruritus and a Suntan That Won't Fade

Eric Fox, DO; Neal T. Patel; Anand D. Patel, MD

Disclosures

June 08, 2021

Physical Examination and Workup

The patient weighs 156 lb (70.8 kg), and his height is 6 ft (182.9 cm). His temperature is 97.3 °F (36.3 °C). His blood pressure is 114/76 mm Hg, his pulse is 72 beats/min and regular, and his respiration rate is 12 breaths/min. The physical examination findings are notable for scleral icterus as well as jaundiced skin. His skin, mainly on his arms and legs, is dark bronze. He notes that the color is darker than his usual summer tan and has persisted into the fall and winter. The liver is palpable underneath the right costal margin, and the site is mildly tender.

Results of hepatitis B and C virus antibody tests are negative. The laboratory analysis is notable for the following findings:

  • Total bilirubin level: 5 mg/dL (reference range, 0.1-1.2 mg/dL)

  • Alpha-fetoprotein (AFP) level: 704 ng/mL (reference range, < 15 ng/mL in adults)

  • Aspartate aminotransferase level: 101 IU/L (reference range, 6-34 IU/L)

  • Alanine aminotransferase level: 70 IU/L (reference range, 20-60 IU/L)

  • Ferritin level: 1805 ng/mL (reference range, 12-300 ng/mL in men)

The remainder of the results of the comprehensive metabolic panel and the complete blood cell count are normal.

CT of the abdomen and pelvis shows moderate ascites, portal gastropathy, cirrhotic morphology of the liver, and a 10.6-cm heterogeneously enhancing right hepatic lobe mass that extends to the liver capsule and is causing extrinsic compression of the biliary tree.

MRI was performed to better characterize the mass observed on the CT scan (see Figures 1-3).

Figure 1.

Figure 2.

Figure 3.

HFE genetic testing reveals that the patient has a homozygous C282Y mutation.

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