A Case of a Boy With Undiagnosed Fibrolamellar Carcinoma Who Died Due to Severe Hemorrhage From Diaphragm

Abstract

An 11-year-old boy presented with vomiting and abdominal pain. Ultrasonography and blood tests revealed no abnormalities. He was diagnosed with viral gastroenteritis; however, the following morning, he was found dead in bed. Postmortem examination revealed that a 1,900 mL hemorrhage with strong coagulation from the diaphragm was the cause of death. He had no traumatic episodes, injuries, or a medical history of hemorrhagic diathesis. The presence of a fibrin-like clot indicated coagulation activation; however, most criteria for disseminated intravascular coagulation were not observed. Fibrolamellar carcinoma, a rare hepatocellular carcinoma, was found; however, liver disorder was not estimated based on the pathological findings. In conclusion, the mechanism of hemorrhage could not be explained. Although we were unable to identify the cause of the hemorrhage, we could not completely rule out the possibility that fibrolamellar carcinoma had an unknown influence on the hemorrhage. Given the limited number of studies on fibrolamellar carcinoma, we present a case of a boy with undiagnosed fibrolamellar carcinoma who died due to severe hemorrhage.

Keywords: child; fibrolamellar carcinoma; hemophagocytosis; internal hemorrhage; legal autopsy.

Figure 1. 1,900 mL of blood with strong coagulation in the abdominal cavity.

(A) there was 1,900 mL of blood in the abdominal cavity. (B) strong coagulation was found in the blood.

Figure 2. Diaphragm and liver post-formalin fixation.

(A) a 4 cm × 4 cm hemorrhage source was observed on the left abdominal side of the diaphragm. (B) a white mass with a diameter of 4.5 cm in the right lobe of the liver, and 1.1 cm and (C) 2.8 cm diameter white masses in the left lobe of the liver were found. (D) The middle of the mass in the right lobe and area above the mass were taken for the histopathological examination.

Figure 3. Microscopic morphology of the diaphragm and sternal bone marrow (hematoxylin and eosin).

(A) Hemorrhage was found from the serosa on the left side of the abdominal cavity of the diaphragm (10x). (B) Hemophagocytosis was identified in the diaphragmatic hemorrhage and (C) sternal bone marrow by using the immersion lens (1000x).

Figure 4. Microscopic morphology of the fibrolamellar carcinoma (hematoxylin and eosin).

Lamellated scars between tumor cells are shown at (A) 10x and (B) at 100x magnification. (C) Large polygonal cells and abundant eosinophilic cytoplasms are shown (1000x). (D) at 40x and (E) at 400x magnification, cancer cells invade the bile duct. (F) Necrosis is seen in the fibrolamellar carcinoma (200x).

Figure 5. A fibrin-like clot observed in the microvessel of the brain (1000x).