Download Breast abscess

A 36 year old female with a
painful, rapidly progressive
breast ulcer.
ID Case Conference
Wednesday, April 11th, 2007
David Fitzgerald, MD
HPI
36 yo WF 3 months s/p C-section delivery of triplets, complicated by post-op
wound infection requiring IV antibiotics, now with a 10 day history of R breast
pain and redness.
► She reports that 10 days prior to presenting to ID clinic she woke up with what
she thought was an insect bite on her R breast with a small area of redness
and tenderness. Over the next several days this progressed to an abscess and
she presented to an urgent care center where an incision and drainage
procedure was performed and she was prescribed keflex.
► Infection initially improved slightly following drainage, however pain increased
and purulent material continued to drain from area. She was contacted by the
urgent care center and informed that the culture grew MR Staph Aureus and
that she should seek further care elsewhere.
► As she was known to ID service at UNC she contacted service over weekend
and was prescibed clindamycin empirically (she has a sulfa allergy). She then
developed fever to 101 and came to ID clinic for follow up.
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HPI
In ID clinic she was noted to be febrile to 39.7, tachycardic
to 140 and hypotensive to 90s/60s. She had a large area
of necrotic tissue and erythema over her R lateral breast
away from the aerola. Purulence was noted from the
wound.
► IV fluids were started. Labs and Bcx obtained. IV
Tigecycline started.
► Urgent US was performed which did not show an abscess
but showed skin thickening and edema.
► Surgery was consulted and the patient was admitted for IV
abx.
► Pt underwent debridement of necrotic tissue on 3/8 with
10x 10 cm area debrided.
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PMH
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1. Post-op C-section wound infection requiring debridement of tissue
on post-op day 12. Cxs only grew CNS. Treated with vanco and
zosyn, but developed fever after discharge, attributed to vanco.
Developed rash to daptomycin started in place of vancomycin.
Restarted vancomycin and developed a rash again. Finished outpt
course with Linezolid and ertapenem but at end of treatment
developed rash.
2. C-section on 12/10/06 with triplets.
3. Two previous episodes of perirectal abscesses in 2001 and 2002.
One episode lead to formation of fistula tract to rectum.
4. Shingles in 2002.
5. Status post myomectomy in 12/05.
6. Hypothryoidism.
7. History of recurrent sinusitis.
SH
► Works
as a computer software developer.
Lives with husband and 3 newborns.
► Denies tobacco, alcohol and illicits.
► No recent travel.
► No pets at home. No recent animal
contacts.
► Ethnically of Ashkenazi/Eastern European
descent.
FH
► Hypertension
and hypercholesterol.
Medications/Allergies
► Medications
 Clindamycin 300 mg
q.8h. Begun 2 days
prior.
 Levothyroid 112 mcg
once daily,
 Multi vitamin
 Tylenol p.r.n.
► Allergies
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Bactrim – resp distress
Vanco – rash, ? Fever
Daptomycin – Rash
Linezolid - Rash
Physical Exam
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Pleasant young woman in
moderate distress
T 39.7 P 140 BP 90/60, RR
18, Sat 98% RA
HEENT Perrla, EOMI,
anicteric, mucous
membranes dry
Neck Supple
Lymph – no cervical, sc lan
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CV – Tachy, regular, no
mrg
Lungs – CTAB
Breast – R breast with 7 x
8 cm area of necrotic
tissue with dark edges and
1-2 cm surrounding
erythema. Purulent
drainage from wound but
no appreciable deep
abscess. Exceedingly
tender to palpation.
Data
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WBC 24 K
 ANC 22.4
 ALC 1.0
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HGB 12.6
Plts 395
ESR 48
Basic WNL with BUN/Cr of
18/0.8
LFTs WNL
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Micro
 Wound swab – 2+ PMNs, no
organisms, no growth.
 BCX x 2 – No growth
 Ucx – no growth
 Prior breast abscess from 5
days prior revealed MRSA
sensitive to clinda (negative
for inducible resistance),
bactrim, vancomycin,
gentamicin and tetracycline
Hospital course
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Patient remained ill with continued tachycardia and hypotension
requiring fluid support for 5 more days. Fevers continued to 39.5.
Continued on Tigecycline. Repeat Bcxs negative.
Due to extension of area of necrosis she required repeat surgical
debridements on
 3/11 (16x 15 cm)
 3/13 (entire lateral aspect of breast and extending medially)
 3/17 (nipple also involved and resected).
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At each operation was noted to have necrosis and purulence of edge of
wound but no deeper infection.
CT chest confirmed that there was no deep abscess or fluid collection.
By hospital day 6 pt was only having low grade temps (38.1), BP stable
and HR down to 80s to 110s but necrosis continued despite clinical
improvement.
Pathology and further micro
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Surgical path
 “The two previous
debridements have been
reviewed. The morphologic
appearance of all three
lesions is similar, showing
large aggregates
of neutrophils accompanied
by epidermal
ulceration. Previous special
stains
have been negative for
bacteria, fungi, and AFB. “
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Micro
 Multiple surgical gram stains
and cultures revealed 2 +
PMNS, no organisms and no
growth.
 One surgical culture grew
coag neg Staph.
►A
consultation was obtained…
Clinical course
All cxs remained negative except for one surgical
cx with CNS
At recommendation of derm, pt was started on
prednisone and antibiotics were eventually
stopped with halt of progression of necrosis
Pt seen in follow up one week after d/c off abx
and on prednisone 100 mg daily with clean
wound edges and no evidence of purulence
Seen also by GI for planned colonoscopy
Immune function testing
► Immunoglobulin
levels – WNL except
slightly high IgE
► NEUTROPHIL OXIDATIVE INDEX - WNL
 Not consistent with CGD
► Leukocyte
adhesion deficiency panel WNL
► HIV negative, CD4 wnl
Pyoderma gangrenosum
A reactive inflammatory dermatosis originally described at Mayo Clinic in 1930.
► Part of the spectrum of neutrophilic dermatoses – which are reactive processes
that have in common:
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1. Non-infectious dermal neutrophilia,
2. Usually an associated condition (inflammatory bowel disease, paraproteinemia, or
arthritis),
3. A tendency for pathergy 4. Similarities in treatment (prednisone and dapsone)
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The neutrophilic dermatoses include
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acute febrile neutrophilic sermatosis (Sweet’s syndrome),
bowel associated dermatosis-arthritis syndrome,
neutrophilic eccrine hidradenitis,
subcorneal pustular dermatosis (Sneddon-Wilkinson Disease)
rheumatoid neutrophilic dermatitis.
SAPHO (synovitis, acne, pustulosis, hyperostosis and osteomyelitis)
A diagnosis of exclusion. Considered a dermatological emergency.
Pyoderma gangrenosum
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Typical course is the rapid progression of a painful,
necrolytic ulcer with an irregular, undermined border.
Usually begins as a nodule or sterile pustule that
progresses to a necrotic and mucopurulent ulcer with an
edematous, violaceous, serpiginously expanding
undermined red-blue border.
The process rapidly destroys skin tissue with a liquefactive
necrosis.
Usually a 1-2 cm halo of erythema around lesion
Usually exceedingly tender (out of proportion to the extent
of the ulcer).
Most frequently affects the LE but can occur anywhere.
Diagnosis
► Diagnosis
of exclusion
► Biopsy necessary to rule out infectious and
vasculitic causes
Major Diagnostic Criteria
 Rapid progression of a painful, necrolytic
cutaneous ulcer with an irregular, violaceous
and undermined border
► Margin
expansion of 1 to 2 cm per day or 50% increase in ulcer size in
one month
► Pain usually out or proportion to size of ulceration
► Ulcer typically preceded by a papule, pustule or bulla
 Other causes of cutaneous ulceration have been
excluded
► Usually
necessitates skin biopsy
Minor Diagnostic Criteria
 History suggestive of pathergy or clinical finding
of cribriform scarring
► Ulcer
development at sites of minor cutaneous trauma
 Systemic diseases associated with PG
► Inflammatory
malignancy
bowel disease, arthritis, IgA gammopathy, or underlying
 Histopathological findings
► sterile
dermal neutrophilia, mixed inflammation, lymphocytic vasculitis
 Treatment response
► Rapid
response to systemic steroid treatment
Associated conditions
► Occur
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in 70% of cases of PG
Inflammatory bowel disease
Seropositive or seronegative arthritis
Myeloma
Paraproteinemia
Diverticulitis
Malignancy (leukemia)
Pathology
► Mixed
cellular inflammation with neutrophil
predominance
Differential Diagnosis
► Vascular
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occlusion or stasis
Antiphospholipid-antidoby syndrome
Livedoid vasculopathy
Venous stasis ulceration
Klippel_Trenaunay_Weber syndrome
Small vessel occlusive arterial disease
Type 1 cryoglobulinemia
Differential Diagnosis
► Vasculitis
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Wegener granulomatosis
Polyarteritis nodosa
Cryoglobulinemic vasculitis
Takayasu arteritis
Leukocytoclastic vasculitis
Differential Diagnosis
► Malignant
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cutaneous involvement
Angiocentric T-cell lymphoma
Anaplastic large-cell T-cell lymphoma
Mycosis fungoides bullosa
Unspecified lymphoma
Leukemia cutis
Histiocytosis X (Langerhans cell histiocytosis)
Differential Diagnosis
► Primary
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cutaneous infection
Sporotrichosis
Aspergillosis
Cryptococcosis
Herpes simplex type 2 virus
Cutaneous tuberculosis
Amebiasis cutis
Zygomycosis
Penicillum marneffei
Differential Diagnosis
► Drug-induced
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& exogenous tissue injury
Munchausen syndrome and factitiousdisorder
Hydrea-induced ulceration
Bromoderma
Contact vulvitis
Drug-induced lupus
Laxoscelism (Brown recluse spider bite)
Injection drug abuse with secondary infection
Differential Diagnosis
► Other
inflammatory disorders
 Cutaneous Crohn disease
 Ulcerative necrobiosis lipoidca
Treatment
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Corticosteroids are mainstay of therapy.
 Usually will have dramatic improvement after 48-72 hours
 Reduced pain and decreased erythema are the most dramatic
markers of response to treatment.
 Halt of enlargement, less induration and less erythema also occur.
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Dapsone, cyclosporine, azathioprine, tacrolimus.
Topical treatments possible with super-potent steroids in
some limited cases.
Often require prolonged course of treatment with slow
taper of immunosuppression
Treatment of underlying disease is also often effective
Reported Effective Treatments
► Corticosteroids
 Systemic, intralesional, topical
► Antimicrobial
agents
 Benzoyl peroxide, clofazamine, dapsone,
rifampicin, lymcycline, tetracycline, minocycline,
mezlocillin, Potassium iodide, sulfapyridine,
vancomycin
Reported Effective Treatments
► Steroid-sparing
immunosuppressive agents
 5-aminosalicylic acid (topical), 6-mercaptopurine, azathioprine,
cholorambucil, cyclophosphamide, cyclosporine( systemic, topical),
methotextrate, mycophenolate mofetil, nitrogen mustard (topical),
tacrolimus (systemic, topical), melphalan
► Immune
modulation
 Infliximab, interferon-a, intravenous y-globulin, plasmapheresis
► Miscellaneous
 Colchicine, nicotine (topical), sodium cromoglycate (topical)
Search PubMed
► Pyoderma
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Gangrenosum
Case Reports
Reviews
Differential Diagnosis
Drug Therapy