Hepatocellular carcinoma is common in patients with cirrhosis regardless of the etiology. Its presentation is uncommon in patients without known cirrhosis. It can spread commonly to the lungs, abdominal lymph nodes and bone but cardiac metastases are rare. The screening and early diagnosis impact the treatment feasibility and prognosis. The most common etiologies of cirrhosis and hepatocellular carcinoma are alcohol consumption and viral hepatitis B and C, however, non-alcoholic fatty liver disease (NAFLD) is becoming a more pronounced known risk factor for steatosis, advanced liver fibrosis, cirrhosis, and thus hepatocellular carcinoma due to the rise of metabolic syndrome prevalence. Although a known risk factor, there are no current recommendations for cancer surveillance in patients with NAFLD. The aim of this paper is to raise awareness of this rising complication by describing a rare initial presentation of hepatocellular carcinoma.