Granuloumatosis Mastitis and Pregnancy

Abstract

INTRODUCTION: Idiopathic granunlomatous mastitis (IGM) is a rare chronic inflammatory disease of the breast with unknown etiology thatusually occurs in young women. It may be confused with breast cancer both clinically and radiologically. The most common clinical presentation is a firm, unilateral breast mass associated with inflammation of the overlying skin. Histologically, it presents with non-caseated granulomas. Other causes of mammary granuloma must be excluded before a confirmative diagnosis. CASE REPORT: DCF, 34 Years Old, presented with painful nodule in left breast and purulent secretion associated with nipple retraction. The patient had no history of connective tissue disease, sarcoidosis, tuberculosis, or other infectious granulomatous diseases. The ultrasound demonstrated a nodule in the ULQ, with 5.0 x 4.0 cm. The patient was submitted to lumpectomy with histological diagnosis of granulomatous reaction. Neither caseous necrosis nor any specific organisms were present. One year later in a follow up visit, patient presented in 7a week of pregnancy with a nodule, blush and pain in upper inner right quadrant. It was prescribed cephalexine and breast ultrasound (US) was requested. US was unspecific, without nodules. The clinical nodule evolved to an abscess in the UIQ and in paraesternal area. These areas were biopsied and the results were steatonecrosis and abscess. PPD reaction was negative. One month later, there was no clinical improvement with cephalexine, development of exophytic granulomatous nodules, and extensive thickening of glandular tissue. New biopsy and betamethasone topical twice daily were prescribed. The new biopsy showed mastitis with steatonecrosis. There was no confirmation of any infectious component. After one month of topical bethametasone, there was total remission of cutaneous lesions and parcial remission of the glandular thickening. It was prescribed prednisone for 3 months with total remission of glandular thickening. The patient had a cesarean delivery and was breastfeeding with two breasts without any problem in her last visit in october 2011. DISCUSSION: IGM remains a challenge to the clinicians regarding diagnosis, differential diagnosis, and treatment options. The cause may be the autoimmune process. Recent history of pregnancy, lactation, and use of oral contraceptive may play an important role in the etiology of IGLM. High levels of serum prolactin as well as distention of the acini and ducts may result in a rupture of these structures, inducing a granulomatous response. Other causes of mammary granuloma formation such as Sarcoidosis, Wegener’s granulomatosis, tuberculosis, and a fungal infection must be excluded before a confirmative diagnosis. No consensus exists on the most appropriate treatment modality for IGM. The most commonly applied treatments are surgical excision and steroid therapy. There are also some reports of treatment with topic corticosteroids. Limited excision alone has little benefit as there is a strong tendency of recurrence. Treatment with corticosteroids provides significant regression of the inflammatory disease, allowing more conservative surgery whens is really necessary.