Plombage Migration Outside the Thoracic Cavity: A Complication of Tuberculosis Treatment

Abstract

An 80 year-old Mexican-American woman presented to the geriatric medicine clinic to establish care and for evaluation of a rapidly enlarging right breast mass. The mass was first noticed in 2003, and at that time a breast biopsy was not performed. The lesion remained relatively constant in size until December 2007. During the subsequent 3 months, the mass grew to involve most of the right breast. Her past medical history was remarkable for pulmonary Mycobacterium tuberculosis treated by right upper lobe collapse and wax plombage in Mexico in the 1950s. Other details from the operation were unavailable. Her other medical problems included hypertension, early Dementia Alzheimer’s Type, and depression. At presentation the patient was afebrile, her blood pressure was 125/70 mm Hg with heart rate of 106 beats per minute. On physical exam, she was thin and pale but in no apparent distress. Lung sounds were absent in the superior right hemithorax with dullness to percussion in that area. Breast exam revealed a painless, diffusely engorged right breast 4 times larger than the left. Superficially, there were dilated subcutaneous veins and nipple inversion. Also present were two 1 1-cm ulcerated skin erosions on the inferior-medial quadrant of the breast. The lesions were covered by a layer of necrotic, white fibrous tissue and were draining frank puslike material. Palpation of the breast expressed a white causeous substance. The breast was diffusely edematous with an approximately 8 3-cm indurated area on the medial aspect. No nipple discharge could be elicited. On palpation of the axilla, a 1 2-cm firm, fixed mass was identified. The patient denied any recent fever, chills, cough, or shortness of breath or weight loss. The patient was admitted to the hospital for evaluation of the mass. Routine laboratory work was significant for a hemoglobin and hematocrit of 9.0 g/dL and 27.5% respectively. Also of note were a decreased mean corpuscular volume of 77.5 FL, elevated ferritin of 313 ng/mL, decreased serum iron of 32 g/dL, transferritin saturation of 23%, and a reticulocyte count of 1.0%. These data suggest that the anemia was due to chronic inflammation. Exudate from one of the lesions was sent for Gram and acid-fast bacilli stain and culture. The culture was positive for coagulase-negative staphylococci, likely representing normal skin flora. These tests were negative for tuberculosis species. Computed tomography (CT) scan of the chest with and without contrast was performed. This test demonstrated a 6.5 3.5-cm soft tissue mass with areas of calcification extending into the right axilla from the pleura with several enlarged axillary, mediastinal and hilar lymph nodes (see Figure 1). There was destruction of the first through third ribs on the right side. Examination of a biopsy of the breast mass tissue showed fat necrosis without evidence of malignant cells. It was determined that this mass represented extrusion of the wax plombage from her operation over 50 years previously. Erosion of the plombage material through the chest wall caused the formation of a cutaneous fistula. The enlarged lymph nodes likely represented reactive changes as a result of a localized inflammatory reaction to the plombage material. DISCUSSION