A 78-year-old Caucasian women presented fever (39°C) and a large, moderately painful ulceration on her right breast which had begun about 10 days ago after quadrantectomy and extended rapidly. Wound and blood cultures yielded negative results. Laboratory investigations: erythrocyte sedimentationrate was 73mm/h, WBC was 22890 mmc; C-reactive protein (CRP) was 25 mg/dl; Protein electrophoresis showed a increase in alfa 2 globulin 15.6%. No clinical response with different antibiotics (imipenem plus teicoplanin; daptomicin + levofloxacin; piperacillin/tazobactam + trimetoprim/sulfamexazole + tigecicline + fluconazole. What is your diagnosis? What do you suggest?
Does the patient have breast cancer? If yes, you should consider inflamatory breast cancer in such a case.
The patient performed breast quadrantectomy for breast cancer. She presented fever and ulceration after sugery.
This atypical ulceration should biopsy for histopathological study.
it seems quite urgent to eliminate neoplastic lesion and another cause culture-negative such as mycobacterium secies or fungis.
Thank You Henk and Maximilian, I agree with your suggestion.Pyoderma gangrenosus is our clinical diagnosis. However, we performed pathergy test, but it was negative. Hystologic study is not yet complete. Microbiologic investigation on biopsy was negative for bacteria, fungi and mycobateria The patient is now on treatment with 60 mg of methylprednisolone.
considering a very high white cell count with relatively low crp we should consider the non infective inflammatory conditions. Pyoderma or necrobiosis lipoidica diabeticorum are such condtions. Waitful watching with sterouds is a wise decision.
Hi Maximilian, at admission in the hospital WBC was 22890 mmc, neutrophils was 84%.
P. gangraenosum was also my first guess. However, the cases of pyoderma gangraenosum I followed developed and worsened within hours to a few days unless steroids were rapidly initiated. And the patient has a history of at least 10 days + negative pathergy... Atypical mycobacteria and fungi may be reconsidered (consider 8-week liquid cultures for mycobacteria). You already treated possible resistant bacteria, and used AB with excellent tissue penetration. What about (in addition to steroids) a try with rifampicin+chinolone (activity against resistant staph etc and mycobacteria). One may also consider an antimycotic therapy against aspergillus/(mucor) if any kind of immunosuppression was present at the time of surgical intervention? Did the patient undergo chemotherapy recently, HIV, diabetes? Did you try pan-bacterial PCR in your samples?
The case is very interesting. However, try to quikly have the pathological examination results, in order to know if neoplastic cells involve the quadrantectomy margins.
The pathological examination of breast cancer showed ductal carcinoma (T1), the quadrantectomy margins were free of neoplastic cells. The subsequent biopsy showed neutrophils, no neoplastic cells and absence of bacteria, fungi and mycobateria. The patient is on treatment with 60 mg of methylprednisolone + tigecycline + piperacillin/tazobactam . The fever and general conditions have improved as well as the pain and local inflammation. We believe that the diagnosis is Pyoderma gangrenosus.
Dear colleague,
The coastal or sternum osteomyelitis should be search by RMI or churgical exploration. We have four cases in our center.
Culture for a possible rapid growing mycobacterial infection (M.cheloni, M.abscessus or M.fortuitum)
We have had a similar very interesting case recently and our dermatology team recommended to stop antibiotics. Only treated with corticoids.
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