When hoofbeats aren’t always horses: Hepatocellular carcinoma rupture in a Tuberculosis‐Endemic Context

Spontaneous rupture of hepatocellular carcinoma (HCC) is an uncommon cause of sudden death, particularly in non-cirrhotic individuals. We report a 59-year-old male who presented with one week of abdominal pain and died unexpectedly. His clinical history included a prior positive GeneXpert test for tuberculosis (2010) and multiple subsequent TB investigations over 15 years, though no record of anti-TB treatment was documented. At autopsy, a massive haemoperitoneum and hepatomegaly were observed, with a focal rupture of the liver capsule. The lungs demonstrated multiple nodules macroscopically suggestive of miliary tuberculosis in a high TB-burden setting. Post-mortem GeneXpert MTB/RIF testing detected Mycobacterium tuberculosis DNA in lung and liver tissue; however, histology revealed no granulomatous inflammation or acid-fast bacilli. Histopathological examination confirmed HCC with regions of both well- and poorly differentiated tumour, vascular invasion, and subcapsular necrosis corresponding to the site of rupture. Pulmonary lesions were consistent with metastatic HCC. This case highlights the diagnostic challenges in high-TB-burden, resource-limited settings, where malignancies may be overlooked due to presumptive attribution of non-specific symptoms to tuberculosis. It underscores the importance of comprehensive differential diagnoses, clinical vigilance, and the value of autopsy in uncovering undiagnosed pathology.