2 Medical Records
2.1 Brief Summary of the Medical Condition
The patient was a 65-year-old female with no history of diabetes or liver disease. She underwent a modified radical mastectomy for a malignant tumour in the left breast on July 4, 2023. Postoperative pathology (left breast) revealed high-grade ductal carcinoma in situ with focal microinvasion. Of the 25 axillary lymph nodes that were examined, one exhibited cancer metastasis (1/25). Immunohistochemistry results were ER (-), PR (-), HER-2 (3+), Ki67 (+, approximately 40%), pT2N1M0, Stage IIB. The postoperative adjuvant therapy plan included four cycles of AC (pirarubicin + cyclophosphamide) chemotherapy followed by sequential THP (Abraxane + trastuzumab + pertuzumab) chemotherapy and targeted therapy. After the third cycle of chemotherapy, the patient experienced a persistent high fever for about a week, reaching a maximum of 39 ℃. Self-administered antipyretic medications did not alleviate the fever, so she sought emergency medical attention at our hospital. The laboratory tests revealed: white blood cell count: 1.3×109/L, absolute neutrophil count: 0.66×109/L, neutrophil percentage: 85.30%, absolute lymphocyte count: 0.57×109/L, platelet count: 102×109/L, C-reactive protein: 245.20 mg/L, alanine aminotransferase (ALT): 53 U/L, aspartate aminotransferase (AST): 117 U/L, gamma-glutamyl transferase (GGT): 140 U/L. Consequently, she was admitted to the hospital on September 21, 2023, for further treatment with a provisional diagnosis of ”chemotherapy-induced bone marrow suppression”.
2.2 Auxiliary Examinations
Following admission, an abdominal CT scan was performed. It revealed a nodule in the right lobe of the liver, raising suspicion of pyogenic liver abscess. A subsequent enhanced liver MRI disclosed two nodules in the VI segment of the liver, with the larger one exhibiting multiple septations and a diameter of approximately 3 cm, indicative of a liver abscess (Figure 1). On the second day of hospitalisation, the patient reported blurred vision and pain in the left eye. Ophthalmologists were consulted, and the results of a visual acuity examination indicated OD 0.8+ and OS 0.6-. Examination of the fundus in the left eye revealed conjunctival congestion, a transparent cornea, numerous dust-like keratic precipitates (KP) in the endothelium, a deep anterior chamber, positive Tyndall phenomenon, a round pupil with 3 mm diameter, delayed light reaction, failure of the lower part of the iris to enter the anterior chamber, and positive tenderness in the upper and lower eyelashes. The intraocular pressure was OD 13.5 mmHg and OS 14.2 mmHg. Moreover, an ocular ultrasound exposed vitreous opacities in the left eye (Figure 3). The provisional diagnosis was left iridocyclitis, and symptomatic treatment with prednisolone acetate eye drops was initiated. However, after two days, the patient’s symptoms worsened, leading to loss of vision in the left eye with purulent discharge. Upon re-examination, ophthalmologists detected mild redness and swelling in the left eyelid, conjunctival congestion and oedema, mild corneal oedema, and increased KP (+++). The anterior chamber was deep with flocculent exudation, while the pupil was not well-rounded, with a diameter of 5 mm, no light reaction, and posterior synechiae. Additionally, the lens was cloudy and no fundus details could be visualised. The intraocular pressure was OD 11.9 mmHg and OS 23.4 mmHg. An orbital CT scan (Figure 4) revealed slight swelling of the soft tissue in the upper eyelid on the left side and exophthalmos of the left eyeball. Subsequently, we made a diagnosis of left endophthalmitis with orbital infection.
2.3 Treatment and Prognosis
After admission, the patient received intravenous ceftazidime for injection (0.2 g Q12H) for anti-inflammatory therapy and subcutaneous injections of granulocyte colony-stimulating factor (G-CSF) (200 μg QD) to stimulate bone marrow haematopoiesis. Following the confirmation of a pyogenic liver abscess, on September 26, 2023, the patient underwent a CT-guided pyogenic liver abscess drainage procedure under local anaesthesia. Bacterial cultures of both blood and pyogenic liver abscess puncture fluid confirmed the presence of Klebsiella pneumoniae. Based on the sensitivity results, the antibiotic was switched to intravenous imipenem (1 g Q8H). After one week of treatment, the patient’s body temperature returned to normal. Besides, a re-examination of the laboratory parameters showed all values within the normal range: white blood cell count: 5.8×109/L, absolute neutrophil count: 4.34×109/L, neutrophil percentage: 74.70%, absolute lymphocyte count: 1.2×109/L, platelet count: 300×109/L, C-reactive protein: 6.87 mg/L, ALT: 35 U/L, AST: 30 U/L, GGT: 40 U/L. A follow-up abdominal CT scan revealed a significant reduction in the volume of the pyogenic liver abscess cavity, with a diameter of approximately 1 cm (Figure 2). After the endophthalmitis diagnosis, ophthalmologists performed intravitreal injections of vancomycin with a concentration of 10 mg/ml and a total volume of 0.1 ml (1 mg). There were three treatment cycles with an average interval of 4 days. During this period, vitrectomy was recommended, but the patient declined. Following systemic and local treatment, the patient’s intraocular infection gradually improved. However, ultimately, permanent blindness occurred in the left eye. The liver drainage tube was removed one month after placement. After discharge, the patient refused to continue chemotherapy due to concerns about further adverse reactions. Currently, the patient is undergoing regular targeted therapy with the HP regimen and no serious adverse reactions have occurred.