ABSTRACT

CORRESPONDING AUTHOR:
Dr. Deepak R. Chavan,
Pragatinagar Ashram Road,
Near Water Tank,
Bijapur-586103,
Karnataka.
Email: dipdeepak@yahoo.co.in

ABSTRACT: Actinomycosis of breast is a rare disease; only 20 cases have been reported. But majority are secondary in presentation. But this study represents the rarest report of primary actinomycosis in postmenopausal woman in India and in the world. A 55 year old presented with a lump, clinically simulating malignancy, in the right breast. Fine needle aspiration was inconclusive. Mammography showed features of malignancy. Modified radical mastectomy was done, histological diagnosis of ACTINOMYCOSIS was made, rare interesting case discussed.

KEYWORDS: Actinomycosis of breast.

INTRODUCTION: Primary actinomycosis of the breast is a rare disease, withfewer than 20 cases reported since its first description byAmmentorp in 1893.^{1, 2} Breast actinomycosis is primary wheninoculation occurs through the nipple. Secondary actinomycosisof the breast refers to the extension of a pulmonary infectionthrough the thoracic cage in a process that can affect the ribs, muscles, and finally, the breast. Distinguishing actinomycosisfrom more common breast lesions such as inflammatory carcinomais difficult. Gogas et al.³ reported that the diagnosis isfrequently made after surgery.

This study is the first to include mammographicfindings of a patient with primary actinomycosis of the breast.In our study, mammography was not suggestive of actinomycosis. After surgery histopathology reportconfirmed it as actinomycosis. In this study we want to state that this condition be considered in the differential diagnosis of intractable breast abscess and malignancy to avoid unnecessary major surgery.

CASE REPORT: A 55yr old post-menopausal female patient was admitted on 07/02/10 with complaints of swelling in the right breast since 3 months, Complains of dull aching pain at the lump site.

On examination left side breast normal. Right side fullness present in the middle and outer quadrant, the nipple inverted and areola distorted on right side. Globular lump measuring about 4x5cm palpable in the retroaeriolar and upper outer quadrant of the right breast. The skin is pinchable (free from the lump).The lump is fixed to the breast tissue and moves with the tissue, No edema, no discharge, no chest wall fixity.

There was 2 palpable lymph node in the right axilla, provisional diagnosis of Carcinoma breast was made stage 2 (T2 N1 M0). FNAC-showed inflammatory changes. Mammography (fig. 1, 2), showed Large irregular homogenous opacity in the retroareolar region and the right upper and outer quadrant with nipple retraction and skin thickening of the right breast, features suggestive of malignancy. Modified Radical Mastectomy was done. Histopathology of specimen showed Features of actinomycosis with multiple micro abscesses. (fig. 3)

An uncommon situation of primary actinomycosis of the breast is reported in a 55-year-old woman who presented with a lump, clinically simulating malignancy, in the right breast. Diagnosis of actinomycosis was could have been established by incision biopsy. Resolution of infection, while conserving the breast, may had been achieved by timely diagnosis, limited surgery, and effective antibiotic therapy.

Diagnostic failures leading to avoidable mastectomies have not been uncommon in cases previously reported in the literature. It is, therefore, imperative that this condition be considered in the differential diagnosis of intractable breast abscess and malignancy.

DISCUSSION: Actinomycosis is caused by gram-positive anaerobic filamentousbacteria that are part of the normal oral flora.^{2, 3} Themost frequent cause is A. israelii, present in 78% of patients.⁴

 Usually, actinomycosis represents a chronic infection characterizedby pus, fibrosis, and fistulas that drain sulfur granules. Thesesulfur granules seen macroscopically represent bacterial coloniesthat appear microscopically as intertwined radiating filaments("rays") terminating in pear-shaped "clubs." These bacterialcolonies may be visualized with Grocott-Gomori coloration.⁵

The main clinical forms of actinomycosis are cervicofacial, thoracic, abdominal, and, in women, pelvic. Dissemination toother organs may occur by spatial contiguity. The disease isfour times more common in men; usually the patients are in otherwisegood health, with no associated diseases.¹

Primary actinomycosis of the breast starts at the nipple; mostof the abscesses are retropapillary.¹ Possible causes ofthis condition observed by Cope and quoted by Lloyd-Davies¹include trauma, lactation, and kissing. All reported cases ofactinomycosis of the breast have involved premenopausal women.This study represents the first case report of primary actinomycosisof the breast in a postmenopausal woman.

Actinomycosis of the breast usually presents as a recurrentabscess, often retropapillary. Fistulas and purulent or bloodydischarge from sinuses may occur. In the most advanced casesof long duration, fibrosis with local cicatrization and architecturaldistortion of the breast tissue are     present.¹. Moreover, disseminationto other organs may occur. Another possible clinical presentationis a chronic abscess of the breast that Lloyd-Davies.¹

Statesis almost impossible to distinguish from inflammatory carcinoma.According to Jain et al.⁶ Primary actinomycosis must beconsidered in the differential diagnosis of chronic breast abscessand malignancy, especially when fine-needle aspiration cytologyof apparently malignant masses suggests chronic inflammation.

The diagnosis is made by pathologic examination of the biopsyor mastectomy specimen, in which we can see the characteristicsulfur granules representing the bacterial colonies.

REFERENCES:

1. Lloyd-Davies JA. Primary actinomycosis of the breast. Br J Surg 1951;38:378 -381[Medline]
2. Apothéloz C, Regamey C. Disseminated infection due to Actinomyces meyeri: case report and review. Clin Infect Dis 1996;22:621 -625[Medline]
3. Weese WC, Smith IM. A study of 57 cases of actinomycosis over a 36-year period: a diagnostic "failure" with good prognosis after treatment. Arch Intern Med 1975;135:1562 -1568[Abstract]
4. Lerner PI. Actinomicose. In: Harrison TR, ed. Medicina interna. Rio de Janeiro: McGraw-Hill, 1995:732 -735
5. Hennrikus EF, Pederson L. Disseminated actinomycosis. West J Med 1987;147:201 -204[Medline]
6. Jain BK, Sehgal VN, Jagdish S, Ratnakar C, Smile SR. Primary actinomycosis of the breast: a clinical review and a case report. J Dermatol 1994; 21: 497 -500[Medline].

Figure 1                                                  Figure 2: MAMMOGRAPHY FILMS

Fig. 3: histopathologic specimen shows filamentous branching bacteria (arrows) positive to silver impregnation, characteristic of grains of Actinomyces israelii.

Figure 3