Scarring moxibustion and religious scarification resulting in hepatitis C and hepatocellular carcinoma

A 66-year-old Somalian man, who had migrated to the USA 2 years previously, presented to us in September, 2005, with a 1-year history of substantial weight loss and intractable itching. Examination was normal except for mild icterus and scar marks on his wrists and abdomen, with mild stigmata of chronic liver disease. Laboratory test results were indicative of abnormal liver function (aspartate aminotransferase 129 IU/L; alanine amino transferase 103 IU/L; albumin 30 g/L; and INR 1·3). Further test results showed presence of hepatitis A IgG antibody, hepatitis B IgG antibody, hepatitis C antibody, hepatitis C virus RNA, and a high α-fetoprotein concentration. An HIV test was negative. CT of the abdomen showed an illdefi ned mass measuring 2·8 cm in the right lobe of liver near the junction of right hepatic vein and middle hepatic vein (fi gure). The possibility of hepatocellular carcinoma secondary to cirrhosis from hepatitis C was considered. However, the patient did not have usual risk factors for hepatitis C (no history of blood transfusion, intravenous drug abuse, haemodialysis, sexual promiscuity, or tattooing). On further questioning, the patient mentioned he practised a procedure known as moxibustion—he would burn specifi c points on his body and cut his wrists and abdomen using sharp objects or needles to release “bad” blood. A close look at his CT scan showed subcutan eous gas in the right anterior abdominal wall, probably secondary to the injections. A liver biopsy confi rmed hepatocellular carcinoma. The patient was referred to the medical oncology service. When seen in February, 2006, he had received two rounds of hepatic chemoembolisation with modest success. Moxibustion and religious scarifi cation are widely practised in some countries. Moxibustion has been used along with acupuncture to treat various ailments, including pain, fatigue, and reverting breech presentation. It can be either direct (scarring and non-scarring), or indirect, based on contact with body surface. Scarring moxibustion, involves stimulation of the body by heat which can be done by burning the herb artemisia—or “moxa” in Japanese. It is also frequently accompanied by cutting the body with knives or needles in an attempt to get rid of toxins in tissue fl uids (scarifi cation). The shared use of non-sterilised needles or knives can predispose recipients to hepatitis B and C, and other infections. Therefore, our patient presumably acquired hepatitis C through sharing of infected knives during the process of scarifi cation or through moxibustion if it involved the use of needles, such as those used in acupuncture. Although intravenous drug abuse is a known risk factor for hepatitis C and HIV infection, the use of injections in other settings—including traditional cultural practices—tends to receive less attention, although these risk factors can account for about a third of cases of hepatitis C. These traditional cultural practices may be less prevalent among people in the USA and Europe, but they are widely practised in other parts of the world, particularly Africa and east Asia. Interestingly, some of these regions have a very high prevalence of hepatitis C, and subsequently hepatocellular carcinoma— this has been attributed to various other causes, including iatrogenic spread. Nevertheless, studies have suggested that folk remedies could contribute towards the high prevalence of hepatitis C seen in some of these regions. Furthermore, a case-control study of 2316 blood donors seropositive for hepatitis C virus in the USA (and 2316 matched seronegative donors) found a higher risk of hepatitis C infection among people who indulged in religious scarifi cation (odds ratio 2·8; 95% CI 1·2–7·0) or body piercing (2·0; 1·1–3·7). Our case report highlights the importance of recognising the medical complications that can occur from seemingly innocuous cultural procedures.