Fatal Bowel Infection After the First Chemotherapy Cycle for Early HER2-Positive Breast Cancer

What happened, in summary

A 76-year-old woman found a lump in the upper outer part of her left breast, despite normal screening mammography and ultrasound 2 months earlier. MRI showed a single 22 mm lesion without regional lymph-node involvement. She underwent lumpectomy with sentinel-node biopsy. Pathology showed a 22 mm grade 3 invasive ductal carcinoma, pT2, with oestrogen receptor expression in 95% of cells, progesterone receptor expression in 90%, and HER2 amplification. The sentinel nodes were negative. Her multidisciplinary team recommended six cycles of docetaxel, carboplatin and trastuzumab, followed by completion of 1 year of trastuzumab, breast irradiation and adjuvant hormone therapy. Eight days after the first TCH cycle, she developed mild painful swallowing and was treated for oral mucositis. The following day, nausea, vomiting, fever and chills developed, followed by a seizure at home. In the emergency department, she had profound neutropenia, low blood pressure, kidney injury and severe metabolic acidosis. CT showed extensive ischaemic bowel changes, gas in the portal and mesenteric veins and pneumoretroperitoneum. Despite immediate broad-spectrum antibiotics, fluids, corticosteroids, defibrillation, intubation and resuscitation, her condition deteriorated rapidly. She died 4 hours after arrival. Blood cultures later grew Clostridium septicum, confirming fulminant sepsis associated with chemotherapy-induced neutropenia and intestinal injury.