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.