Hepatocellular Carcinoma Presenting With Worsening Microcytic Anemia and Intratumoral Hemorrhage

Hepatocellular carcinoma (HCC) typically presents with right upper quadrant pain, jaundice, or ascites.Acute spontaneous tumor rupture is a well-recognized emergency, but insidious, chronic bleeding into the tumors, presenting as iron deficiency anemia (IDA) before an acute hemorrhagic crisis, is exceedingly rare.This diagnostic challenge is further compounded in patients with concurrent hereditary hemoglobinopathies.A 69-year-old postmenopausal woman with alpha-thalassemia minor and no prior history of chronic liver disease presented with progressive fatigue.Laboratory evaluation revealed profound IDA.While awaiting gastrointestinal endoscopic evaluation to rule out occult luminal bleeding, she developed sudden, severe abdominal pain.Abdominal MRI and CT showed hepatomegaly with multiple bilateral hepatic masses with signs of subcapsular intratumoral hemorrhage, along with an elevated alpha-fetoprotein (AFP) level (110 IU/mL).Upper endoscopy and colonoscopy identified no source of gastrointestinal bleeding.The patient subsequently developed a catastrophic tumor rupture with active bleeding from two distinct lesions, and her hemoglobin fell below 6 g/dL.She underwent emergent transarterial embolization of three hepatic tumors, which achieved stabilization.A core needle biopsy confirmed well-differentiated HCC.Because of her high tumor burden, she was started on systemic immunotherapy but unfortunately passed away one month later.In rare cases, chronic, occult intratumoral hemorrhage from HCC can masquerade as standard IDA before progressing to serious and potentially life-threatening rupture.Hepatic malignancies should be considered in the differential diagnosis of unexplained microcytic anemia when standard endoscopic evaluations are negative, particularly when underlying hemoglobinopathies cloud the clinical presentation.Maintaining clinical awareness and considering early cross-sectional abdominal imaging in these atypical scenarios may assist in identifying subcapsular lesions before macro-structural failure.