AJR 2000; 174:1087-1088
© American Roentgen Ray Society
Herpes Simplex Virus Mastitis
Clinical and Imaging Findings
Mary Scott Soo1 and
Sujata Ghate2
1
Department of Radiology, Breast Imaging Division, Duke University Medical
Center, Box 3808, Hospital South, Rm. 24244B, Durham, NC 27710.
2
Breast Imaging Clinic, Emory University Medical Center, 1365 Clifton Rd.,
Bldg. B, Atlanta, GA 30322.
Received July 21, 1999;
accepted after revision September 10, 1999.
Address correspondence to M. S. Soo.
Introduction
Herpes simplex virus is a rare cause of breast infection. Few cases of
maternal-infant transmission of the virus during breast-feeding resulting in
nipple lesions have been documented
[1,2,3,4],
and only two cases have been reported in nonlactating women. The imaging
findings of herpes simplex virus mastitis have not, to our knowledge, been
reported. We report a case of herpes simplex virus infection of the breast
that presented with clinical and imaging findings similar to those of
inflammatory breast carcinoma.
Case Report
A 50-year-old nulliparous woman presented to her breast surgeon with a
1-month history of localized excoriation at the tip of the right nipple,
redness and swelling in the periareolar area, and right breast pain. She
described a 2-week history of clear and serosanguinous nipple discharge. The
patient had a history of multiple cyst aspirations but had no personal history
of breast cancer. Her past surgical history was significant for hysterectomy
and bilateral salpingo-oopherectomy. She reported no personal history of
herpes simplex virus infections, although in retrospect she reported that her
sexual partner had a herpes lesion on her hand.
Physical examination of the right breast revealed skin edema with peau
d'orange and erythema of the skin in the subareolar and periareolar regions. A
4-mm localized excoriation at the tip of the right nipple was noted. In
addition, a suspicious 1-cm firm, mobile lymph node was palpated in the right
axilla. Two palpable breast cysts were detected and resolved with aspiration.
The left breast was normal on physical examination and no axillary adenopathy
was palpable.
Mammography showed dense fibroglandular tissue bilaterally with increased
density of the right breast compared with that of the left (Figs.
1A and
1B). Multiple bilateral masses
were present, some of which had fluctuated in size since the previous study,
suggestive of cysts. Skin thickening was present on the right breast.
Sonography revealed areas of diffuse skin thickening correlating to the areas
of peau d'orange on physical examination
(Fig. 1C). Multiple simple
cysts were identified correlating with the palpable masses; no suspicious
masses were seen.
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Fig. 1A. —50-year-old woman with herpes simplex virus mastitis. Mediolateral
oblique mammograms show diffuse density throughout right breast (A) as
asymmetric compared with normal left breast (B). Asymmetry is related
to mastitis and large cysts.
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Fig. 1B. —50-year-old woman with herpes simplex virus mastitis. Mediolateral
oblique mammograms show diffuse density throughout right breast (A) as
asymmetric compared with normal left breast (B). Asymmetry is related
to mastitis and large cysts.
|
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Fig. 1C. —50-year-old woman with herpes simplex virus mastitis. Extended
field-of-view sonogram shows diffuse skin thickening (open arrows)
related to mastitis extending inferiorly from nipple (solid arrow).
Thickening is decreased to normal state (arrowheads) peripherally
where skin covers large simple cyst.
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Fine-needle aspiration of the right axillary lymph node revealed
lymphocytes and macrophages that were consistent with a benign reactive lymph
node. Punch biopsies of the nipple and adjacent skin showed dense neutrophilic
and lymphocytic infiltrate within an ulcer bed that was consistent with
herpetic dermatitis. Results of immunohistochemical studies revealed
expression of herpes simplex virus antigens. The patient was treated with oral
acyclovir for 7 days with complete resolution of her symptoms.
Discussion
Herpes simplex virus is a rare infection of the breast. Four cases of
maternal-infant transmission during breast-feeding have been reported
[1,2,3,4],
and two other cases of infection unrelated to maternal-infant transmission
have been described [5]. The
reported physical findings in patients with nipple lesions and discharge
attributed to herpes simplex virus included crusted nipple lesions with
ulceration either limited to the tip of the nipple or extending to the areola.
However, no previous reports have described physical findings of extensive
erythema, skin thickening, and peau d'orange appearance, which in our patient
were suggestive of inflammatory breast carcinoma with Paget's disease of the
nipple.
The imaging findings of herpes simplex virus of the breast have not, to our
knowledge, previously been reported. Our case shows that findings of herpes
simplex virus mastitis are similar to those of mastitis resulting from other
causes [6], with diffuse
asymmetric density and skin thickening. Normal breast skin thickness is less
than 3 mm. In our patient, the skin thickness measured 5 mm and was associated
with physical findings of peau d'orange and erythema. The differential
diagnosis of unilateral skin thickening and asymmetric density is extensive,
including inflammatory carcinoma, postradiation change, mastitis, trauma,
lymphedema, previous surgery or trauma, and congestive heart failure in
patients lying in a decubitus position
[7]. Herpes simplex virus
mastitis is a rare cause of mastitis, which in our patient was difficult to
distinguish clinically, mammographically, and sonographically from
inflammatory carcinoma. Although biopsy and immunohistochemical staining are
necessary to exclude a malignant process and confirm the diagnosis, herpes
simplex virus should be included in the differential diagnosis of unilateral
asymmetric density and skin thickening, especially when excoriation of the
nipple is identified on physical examination.
Acknowledgments
We thank J. Dirk Iglehart for his input in this case.
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Introduction
Case Report
