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Case Report |
1
Radiology Department, São Paulo University,
Medical School, Eneas de Carvalho Aguiar, 255,
São Paulo, CEP 05403-900 Brazil.
2
Gynecology Department, São Paulo University,
Medical School, São Paulo, CEP 05403-900
Brazil.
Received September 10, 1999;
accepted after revision November 23, 1999.
Address correspondence to N. de Barros, Rua Sampaio Vidal, 185, J.
Paulistano, São Paulo, CEP 05403-900
Brazil.
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To our knowledge, this study is the first to include mammographic findings of a patient with primary actinomycosis of the breast. In the patient in our study, mammography suggested a diagnosis of inflammatory carcinoma that sonographic, CT, and pathologic examinations later confirmed as actinomycosis. In addition, this study represents the first report of primary breast actinomycosis in a postmenopausal woman.
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No history of lung disease, breast trauma, gingivitis, or tooth problems was found. Physical examination was significant for a breast mass at the juncture of the superior quadrants of the left breast (between the 11- and 2-o'clock positions). Multiple fistulas in this area drained pus. The breast was hyperemic and tender to palpation, but the patient was afebrile and appeared otherwise healthy. No palpable adenopathy was found.
Mammography showed large breasts, with the left breast larger than the right. Skin at the union of the superior quadrants of the left breast appeared irregular and thickened; an irregular mass with spiculated contours was seen (Figs. 1A and 1B). Microcalcifications were not observed. The tentative diagnosis was inflammatory carcinoma based on mammographic findings or actinomycosis based on the previous diagnosis.
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Sonography of the left breast revealed hypoechogenicity of subcutaneous tissues mainly in the superolateral and inferolateral quadrants. Multiple collections of thickened liquid with fistulas draining to the skin were seen. The largest collection of fluid was 6.3 x 1.7 cm, located between the 11- and 1-o'clock positions; its deepest point was 4 cm below the skin. Another collection of fluid without fistulas was seen in the internal quadrants; this pocket measured 4.0 x 1.5 cm at a depth of 4 cm (Fig. 1C). Neither muscular extension nor nodules were observed.
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Contrast-enhanced CT revealed enlargement of the left breast, cutaneous thickening, and a collection of fluid with defined limits. No signs of intrathoracic, bone, or muscular extension of the disease process were seen (Fig. 1D). Bone scintigraphy (not shown) revealed increased uptake only in the left breast projection, with no rib lesions.
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After informed consent was obtained, the patient was taken to surgery, and the abscesses and the fibrous tissue were drained and resected. Pathologic examination of a 7 x 4 x 3 cm tissue specimen suggested extensive chronic granulomatous inflammation with grains of Actinomyces israelii diagnosed through histochemical analysis that showed filamentous branching bacteria positive to silver impregnation (Grocott-Gomori methenamine-silver nitrate stain) and negative to the Ziehl-Neelsen stain (Fig. 1E). Cytology was positive for inflammatory cells and negative for neoplastic cells.
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The therapeutic plan consisted of 65 days of 24 million U/day of IV penicillin to be followed by the administration of amoxicillin, 500 mg 3 times a day for another 6 months. The patient responded to the treatment and is doing well.
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The main clinical forms of actinomycosis are cervicofacial, thoracic, abdominal, and, in women, pelvic. Dissemination to other organs may occur by spatial contiguity. The disease is four times more common in men; usually the patients are in otherwise good health, with no associated diseases [1].
Primary actinomycosis of the breast starts at the nipple; most of the abscesses are retropapillary [1]. Possible causes of this condition observed by Cope and quoted by Lloyd-Davies [1] include trauma, lactation, and kissing. All reported cases of actinomycosis of the breast have involved premenopausal women. This study represents the first case report of primary actinomycosis of the breast in a postmenopausal woman.
Actinomycosis of the breast usually presents as a recurrent abscess, often retropapillary. Fistulas and purulent or bloody discharge from sinuses may occur. In the most advanced cases of long duration, fibrosis with local cicatrization and architectural distortion of the breast tissue are present [1]. Moreover, dissemination to other organs may occur. Another possible clinical presentation is a chronic abscess of the breast that Lloyd-Davies [1] states is almost impossible to distinguish from inflammatory carcinoma. According to Jain et al. [8], primary actinomycosis must be considered in the differential diagnosis of chronic breast abscess and malignancy, especially when fine-needle aspiration cytology of apparently malignant masses suggests chronic inflammation.
The diagnosis is made by pathologic examination of the biopsy or mastectomy specimen, in which we can see the characteristic sulfur granules representing the bacterial colonies. The Grocott-Gomori coloration helps in establishing the diagnosis because it allows visualization of organisms with filamentous branching observed in fungus and some bacteria such as A. israelii and Nocardia organisms. The latter can be excluded by a negative Ziehl-Neelsen coloration, which was observed in our patient. The culture yields positive results in only 50% of patients and should be performed with both aerobic and anaerobic media [8]. A. israelii is frequently associated with other bacteria, such as Streptococcus organisms, Escherichia coli, and Pseudomonas organisms. The presence in histologic sections of granules composed of actinomycotic colonies and showing a characteristic appearance establishes the diagnosis when culture is unsuccessful or suitable specimens for culture are not available [8]. When fistuals are present, Lloyd-Davies [1] stated that it is important to exclude chronic suppurative mastitis, tuberculosis, syphilis, and chronic osteomyelitis of the ribs. The differential diagnosis should include inflammatory carcinoma. Treatment consists of the prolonged administration of penicillin and, if necessary, surgery. The domiciliary administration of oral amoxicillin provides excellent long-term results [8].
Our findings are significant because this study represents the first reported case of primary breast actinomycosis in a postmenopausal woman. Our findings also illustrate the importance of using imaging and pathologic studies in addition to mammography in some cases of suspected inflammatory carcinoma. Although sonography and CT may differentiate an inflammatory process from a neoplastic process by identifying an abscess, we believe that distinguishing breast actinomycosis from tuberculosis and other potential diagnoses is possible only through pathologic examination. Pathologic examination in cases of actinomycosis usually reveals non-acid-fast gram-positive organisms with filamentous branching that appear grossly as sulfur granules.
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