On September 17, 2019, a 65-year-old man was referred to our hospital with nausea and abdominal distension accompanied by fatigue and dizziness for 10 days, and a significant weight loss of 3 kg over 2 months. He had experienced chronic viral hepatitis B 20 years previously, treated with entecavir once a day. After hospitalization, physical examination revealed abdominal distension, a temperature of 37 °C, blood pressure of 125/72 mmHg, heart rate of 78 bpm, and respiratory rate of 18 bpm. Results of laboratory investigations were as follows: quantitative hepatitis B surface antigen (> 250 IU/mL) and HBV-DNA (2.97 × 10
5 IU/mL). Routine hematological results included white blood cells (5.2 × 10
9/L) with 68.9% neutrophils, lymphocytes (1.15 × 10
9/L), red blood cells (4.45 × 10
12/L), hemoglobin (129 g/L), and platelets (294 × 10
9/L). Levels of high-sensitivity C-reactive protein (CRP) were 18.8 mg/L, and PCT level was > 100 ng/mL. Mild hepatic dysfunction was noted with an alanine aminotransferase (ALT) level of 76 IU/L, aspartate aminotransferase (AST) level of 53 IU/L, globulin (34.1 g/L), and albumin (34.6 g/L). Coagulation tests were slightly abnormal: prothrombin time (PT), 13.9 s; activated partial thromboplastin time (APPT), 33.4 s; and fibrinogen, 4.6 g/L. Renal function was essentially normal. No abnormal tumor markers were detected, except for abnormal levels of glycoproteins, at 4824 ng/ml. An initial chest CT revealed multiple subpleural nodules in the lower lobes of both lungs and the upper lobe of the right lung. Abdominal ultrasound indicated multiple hepatic masses. Contrast-enhanced CT of the whole abdomen revealed a massive left lobe hepatocellular carcinoma with multiple loci, cirrhosis, splenomegaly, and gallstones. Enhanced magnetic resonance (MRI) of the liver also showed a massive left lobe hepatocellular carcinoma with multiple loci, cirrhosis, and multiple cysts. The patient had a relatively definitive diagnosis, and was therefore treated with compound glycyrrhizin and reduced glutathione to relieve the hepatitis, via the effects on reducing enzymes and protecting hepatocytes. Entecavir was provided as an antiviral. The standard care for chronic liver disease was also administered. The patient multifocal tumors was lack of indications of resection according the practice guidelines for the management of hepatocellular carcinoma [
5]. Therefore, he underwent transcatheter hepatic arterial chemoembolization (TACE) on September 23, 2019. Preoperative review of the laboratory tests showed that the PCT level had twice remained > 100 ng/mL, with no significant changes in the other indices. On the first day after surgery, the patient developed fever with a daily maximum temperature of 39.2 °C, but had no obvious discomfort other than slight fatigue. The white blood cell count was 6.2 × 10
9/L with 94.1% neutrophils, CRP level was 28.7 mg/L, and the PCT level remained > 100 ng/mL. In view of the secondary response after the procedure and the possible absorption of necrotic materials from the carcinoma, the patient was given a non-steroidal anti-inflammatory drug, and an antibiotic (imipenem, 0.5 g three times daily). After 4 days, his temperature had decreased to 37 °C. Given the improvement in his clinical condition, the patient was discharged on September 30.
The second and third TACE procedures were performed on October 18 and December 11, 2019. Similarly, the patient developed fever with a daily maximum temperature of 39 °C approximately 1 day after each surgery. During the second hospitalization, the white blood cell count was 6.1 × 10
9/L with 87.1% neutrophils, and the PCT level remained > 100 ng/mL on the first day after TACE. Ferritin level was 1511 ng/mL, and glycoprotein levels were abnormal, at 2455 ng/mL. The patient was not obviously uncomfortable, and he was treated with non-steroidal anti-inflammatory drugs. His temperature decreased to 37.8 °C before discharge from the hospital. During the third hospitalization, the white blood cell count was 6.9 × 10
9/L with 90.7% neutrophils, and PCT level remained > 100 ng/mL on the first day after TACE. Ferritin level was 835 ng/mL. The patient had no obvious discomfort and was again given non-steroidal anti-inflammatory drugs. During the three hospitalizations, the patient underwent several contrast-enhanced CTs or MRIs to estimate the tumor extent or progression. The radiographic imaging always indicated giant multiple tumors, despite treatment. Lung CT scan was also underwent for differential diagnosis between benign and malignant pulmonary nodules. The application of radiological feature analysis may be particularly suited to the assessment and management of pulmonary nodules [
6,
7]. Benign nodules usually smooth, round and poor growth. The size and distribution of nodules of lung metastatic tumor were not uniform density, lobulated, sometimes rough edges or ground-glass opacity [
8]. The size developed rapidly and the number of nodules increased [
9]. In this case, the nodules were smooth and round without lobulated. The size, density and morphological features of the major nodules in the upper lobe of the right lung remained stable (Sup
1) without systemic treatment, indicating no obvious changes during the several months.