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| CASE REPORT |
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| Year : 2022 | Volume
: 17
| Issue : 3 | Page : 729-730 |
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Idiopathic necrotizing fasciitis of the breast
Siddharth Pramod Dubhashi
Department of Surgery, All India Institute of Medical Sciences, Nagpur, Maharashtra, India
| Date of Submission | 17-Apr-2020 |
| Date of Decision | 18-Sep-2021 |
| Date of Acceptance | 22-Oct-2021 |
| Date of Web Publication | 2-Nov-2022 |
Correspondence Address:
Prof. Siddharth Pramod Dubhashi
A2/103, Shivranjan Towers, Someshwarwadi, Pashan, Pune - 411 008, Maharashtra
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jdmimsu.jdmimsu_130_20
Necrotizing fasciitis of the breast is extremely rare. This is a report of a 41-year-old woman with idiopathic necrotizing fasciitis of the breast, who was managed successfully with a good index of clinical suspicion, early surgical intervention, parenteral antibiotics, and nutritional support. This helped in further spread of local infection, minimizing the damage to the breast parenchyma.
Keywords: Antibiotics, breast, necrotizing fasciitis, surgical debridement
How to cite this article:
Dubhashi SP. Idiopathic necrotizing fasciitis of the breast. J Datta Meghe Inst Med Sci Univ 2022;17:729-30 |
| Introduction | |  |
Necrotizing fasciitis is a fulminating soft-tissue infection characterized by edematous myonecrosis. The condition is associated with significant morbidity and mortality and commonly affects the perineum, extremities, and lower abdomen.[1] Necrotizing fasciitis of the breast is a rare entity, presenting as primary infection or secondary to trauma and interventions.[2],[3] A strong index of suspicion is warranted to have a timely diagnosis and aggressive surgical approach.[4]
| Case Report | | |
A 41-year-old woman presented to the surgical emergency with pain and swelling in the left breast for 4 days. The lesion had a history of abrupt onset with no clear predisposing factor or etiology. On examination, she was febrile with tachycardia. Locally, there was evidence of diffuse erythema, marked tenderness, subcutaneous crepitus, and edema associated with skin mottling [Figure 1]. There was no axillary lymphadenopathy. Laboratory investigations revealed anemia (hemoglobin: 9.1 g%), leukocytosis (total leukocyte count: 28,300/mm3), elevated C-reactive protein levels, and hyponatremia (126 mMol/L). The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score was 10. Blood sugar levels were normal. Chest X-ray was unremarkable. Fine-needle aspiration revealed frank pus. A primary diagnosis of necrotizing fasciitis of the breast was made, and parenteral antibiotics including metronidazole were started. The patient was taken up for emergency surgical debridement. Around 70 cc purulent fluid was drained and all necrotic breast tissues were excised [Figure 2]. The specimen was sent for anaerobic culture. The wound was given a thorough lavage with hydrogen peroxide and packing done. The pack was removed 24 h later. Daily wound dressings continued with antibiotic cover. Culture reports confirmed a polymicrobial infection with isolates of Staphylococcus aureus, Streptococcus pyogenes, Proteus, and Klebsiella sp. sensitive to cephalosporins and aminoglycosides. The patient required one more local debridement on the 5th postoperative day. Thereafter, the wound started granulating rapidly over the next 10 days.
| Discussion | | |
The first description of necrotizing fasciitis was given by Jones in 1871.[5] The term necrotizing fasciitis was proposed by Wilson in 1952.[6] The toxins produced by the bacteria cause local microvascular thrombosis and tissue ischemia with sepsis.[7] Various predisposing conditions include trauma, immunosuppression, diabetes, vascular disorders, minor surgical procedures, and puerperal sepsis. It can be a polymicrobial infection including anaerobes (Type I) (as in our case), or a Group A streptococcal infection with or without staphylococci (Type II), or infection due to marine insects (Type III).[8] The first case of necrotizing fasciitis of the breast was reported by Shah et al.[9] in a 50-year-old diabetic female. Very few cases[1],[4],[10],[11],[12] of necrotizing fasciitis of the breast have been reported in the literature till date, and an idiopathic lesion, as seen in our case, is extremely rare. Spontaneous necrotizing soft-tissue infection of the breast has been reviewed by Stoeckl et al.[13]
The diagnosis of this condition is clinical. The local signs in initial stages can be similar to cellulitis or mastitis. The LRINEC score (score range: 0–13) is a useful guide for risk stratification: low (≤5), intermediate (6–7), and high (≥8).[14] Imaging studies can aid in defining the inflammatory process and mapping of lesions for precise surgical intervention. No additional radiological investigations were done in our case, owing to the LRINEC score of more than 10. The treatment guidelines comprise resuscitation, early surgical intervention, appropriate use of antibiotics, wound re-exploration after 24 h, and delayed wound closure.[1],[4],[9],[10],[11]
| Conclusion | | |
Necrotizing fasciitis of the breast is a rare condition with a potential for life-threatening complications, if not detected early. Aggressive surgical approach can help in minimizing the damage to the breast parenchyma, thereby obviating the necessity of subsequent reconstructive procedures.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Konik RD, Cash AD, Huang GS. Necrotizing fasciitis of the breast managed by partial mastectomy and local tissue rearrangement. Case Reports Plast Surg Hand Surg 2017;4:77-80.  |
| 2. | Shimizu T, Tokuda Y. Necrotizing fasciitis. Intern Med 2010;49:1051-7. |
| 3. | Cocco D, Davis J, Kowal-Vern A, Wilson W, Komenaka I, Matthews MR, et al. Necrotizing fasciitis of the male and female breast: A case series. Int J Plastic Surg 2019;14:1-7. |
| 4. | Ward ND, Harris JW, Sloan DA. Necrotizing Fasciitis of the Breast Requiring Emergent Radical Mastectomy. Breast J 2017;23:95-9. |
| 5. | Jones J. Surgical Memoirs of the War of the Rebellion: Investigation upon the Nature, Causes and Treatment of Hospital Gangrene as Prevailed in the Confederate Armies 1861-1865. New York, NY: US Sanitary Commission; 1871. |
| 6. | Wilson B. Necrotizing Fasciitis. Ann Surg 1952;18:416-431. |
| 7. | Cainzos M, Gonzalez-Rodriguez FJ. Necrotizing soft tissue infections. Curr Opin Crit Care 2007;13:433-9. |
| 8. | Soliman MO, Ayyash EH, Aldahham A, Asfar S. Necrotizing fasciitis of the breast: A case managed without mastectomy. Med Princ Pract 2011;20:567-9. |
| 9. | Shah J, Sharma AK, O'Donoghue JM, Mearns B, Johri A, Thomas V. Necrotising fasciitis of the breast. Br J Plast Surg 2001;54:67-8. |
| 10. | Yaji P, Bhat B, Harish E. Primary necrotising fasciitis of the breast: Case report and brief review of literature. J Clin Diagn Res 2014;8:ND01-2. |
| 11. | Fayman K, Wang K, Curran R. A case report of primary necrotising fasciitis of the breast: A rare but deadly entity requiring rapid surgical management. Int J Surg Case Rep 2017;31:221-4. |
| 12. | ALShareef B, ALSaleh N. Necrotizing fasciitis of the breast: Case report with literature review. Case Rep Surg 2018;2018:1370680. |
| 13. | Stoeckl E, Dedhia PH, Wilke LG, Long KL. Necrotizing soft tissue infection of the breast: Bilateral presentation in a male patient. Ann Breast Surg 2019;3:19. |
| 14. | Wong CH, Khin LW, Heng KS, Tan KC, Low CO. The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score: A tool for distinguishing necrotizing fasciitis from other soft tissue infections. Crit Care Med 2004;32:1535-41. |
[Figure 1], [Figure 2]
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