An unusual case of markedly elevated AFP in a case of decompensated cirrhosis without HCC

Background and Aim: Alpha fetoprotein is a fetal specific glycoprotein normally produced during gestation by fetal liver and yolk sac. Apart from HCC, Elevated levels of AFP in Cirrhosis can be seen in acute and chronic viral hepatitis. However, AFP levels > 400 ng/ml in a cirrhotic is highly suspicious of HCC. We present a case of decompensated cirrhosis with acute portal vein thrombosis (PVT) having markedly elevated AFP levels without evidence of HCC. Case report: A 67-year-old male, a known case of T2 DM presented with abdominal distension and pain abdomen for 2 weeks. There was no history of hematemesis or melena. He was a teetotaler. Physical examination revealed pallor, distended abdomen with shifting dullness. Laboratory evaluation revealed hypoalbuminemia and mild anemia. Ultrasound abdomen showed features of cirrhosis of liver, acute portal vein thrombosis and moderate ascites. Ascitic fluid analysis showed High SAAG, low protein with no SBP or atypical cells. EGD showed Large esophageal varices with RWS. EVL was done. Serum AFP sent in view of Acute PVT was 1210 ng/ml. A Triphasic CT abdomen showed features of cirrhosis of liver, acute portal vein thrombosis with no focal lesion suggestive of HCC. USG guided biopsy of liver revealed cirrhosis without evidence of HCC. An etiological workup of cirrhosis showed negative Hepatitis B and C serology, HbeAg was negative, Total Anti-Hbc was negative, HBV DNA was not detected. A probable diagnosis of cirrhosis due to NASH was made. He was started on anticoagulation with LMWH. Conclusion: Significant elevations of AFP in a cirrhotic patient in the absence of radiological and histological evidence of HCC can be challenging for clinicians. Whether acute PVT is the cause for the marked elevation of AFP in such patients is not well understood and is documented only in few isolated case reports.