Ali Kavyani

Amirhosein Jalali

Arash Najaf

Farzaneh Ebrahimi-Fard

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Introduction 
Idiopathic granulomatous mastitis (IGM),
first described by Kessler and Wolloch in 1972,
is a rare benign inflammatory disease of the
breast in young women. Clinically and histo-
logically, it is a mimicker of acute infection or
carcinoma of the breast. 
Its etiology is unknown, and autoimmune
pathogenesis has been advocated. Histological-
ly, the disease is characterized by the occur-
rence of numerous granulomatous lesions with
multinucleated cells of the Langhans type and
focal central necrosis [1].    
All specific infectious, granulomatous and
neoplastic diseases must be excluded for a cor-
rect therapeutical approach [2]. Idiopathic
granulomatous is mastitis (IGM) characterized
by non-caseating granulomata and microab-
scesses limited to breast lobules. The disease is
presented mostly by multiple and recurrent
breast abscesses or a firm mass that is clinically
and radiologically not distinguished from
breast cancer. Frequently, patients are young
and multiparous women, some, complain of
mastalgia [1-4].
Almost always, the condition is diagnosed
after surgical interventions (excisional or inci-
sional biopsy). Two cases referred to the surgi-
cal ward and were candidates for mastectomy
due to the high suspicion of breast cancer or in-
flammatory carcinoma.They were treated post-
operatively as having tuberculosis(TB) and de-
veloped2 chronic sinus after antitubercolous
empiric chemotherapy. For this reason, this dis-
ease is explored and reviewed in the literature.
Although some organisms may be found in
the lesions of granulomatous mastitis, they are
Case Report
Idiopathic granulomatous mastitis: report of 3 cases and a review of
the literature 
Farzaneh Ebrahimi-Fard, MD1, Arash Najaf beygi, MD2., Ali Kavyani, MD3,
233 Amir Hosein Jalali, MD4
Shahid Modarres Hospital, Shahid Beheshti University of Medical Sciences, Tehran,Iran.
Absract
Idiopathic granulomatous mastitis is a rare, inflammatory, and benign breast dis-
ease characterized by non-caseating granulomata and microabscesses limited to
breast lobules. This condition presents as a firm breast mass that is clinically and ra-
diologically indistinguishable from breast cancer, or as multiple or recurrent ab-
scesses, or mastitis in a young non-lactating woman.  Almost always, the diagnosis is
made after surgical interventions to rule out other  pathologies as differential diag-
noses especially tuberculosis which is endemic in our country.
We are going to report 3 cases of granulomatous mastitis besides a brief review of
the literature. We emphatically  recommend that although this entity should be kept
in mind as a rare differential diagnosis, it shoud not be considered as the first one.           
Keywords: Chronic mastitis, Breast mass, Breast abscess, Granuloma , Idiopath-
ic granulomatous mastitis
1. Assistant Professor of General Surgery, Shahid Baheshti University of Medical Sciences and Health Services.
2. Corresponding author, General Surgery Resident; Shahid Beheshti University of Medical Sciences;Tehran, Iran. Tel: +98 9124849963; 
Email: a.najafbeygi@yahoo.com
3&4.General Surgery Resident; Shahid Beheshti University of Medical Sciences, Tehran, Iran.
Medical Journal of the Islamic Republic of Iran.Vol. 23, No. 4,  February 2010. pp. 233-237
not supposed to be the causative agents and as a
matter of fact, the disease is idiopathic [4]. This
condition must be differentiated from the other
granulomatous diseases such as tuberculosis.
Granulomatous mastitis has a great tendency to
recur but usually resolves spontaneously even
without treatment [2-4]. 
There is no consensus about the best treat-
ment for this disease but it is believed that prop-
er management and close follow-ups are the
preferred choices. Steroids have been used in
the treatment course and considered effective in
some recurrent or intractable ones but, drug
side effects or relapse may be inevitable. In a
study conducted in Australia, methotrexate was
trialed in refractory cases after surgery or a
course of steroid therapy and associated with
successful results [5]. It is obvious that surgical
intervention per se, can not prevent recurrence
of the disease and actually can lead to wound in-
fection persistent wound discharge, suppura-
tive sinus formation or even wound nonhealing
[6,7]. On the other hand, it is necessary to have
histologic confirmation and also surgical sam-
pling is inevitable [8]. 
For abscesses, simple drainage accompanied
by incisional biopsy of the abscess wall is ade-
quate and constitutes the standard treatment
[8]; but for a breast mass that mimics cancer, it
is preferred to obtain a tissue sample by fine-
needl-aspiration (FNA) or core needle biopsy
[5,9]. Needle aspiration or a small incision to
drain abscesses is preferred if feasible.
Both  the aforementioned procedures were
performed by the author and then reported on
this paper. 
Case reports
Case 1: 
A 41-year-old multiparous woman was re-
ferred to the surgical ward because of pain in
the right breast in addition to a palpable mass
with sorrounding erythema. She also com-
plained of nipple purulent discharge.The symp-
toms were initiated one month prior to admis-
sion and she was febrile when referred. She had
a history of the same breast abscess drainage
last year, accompanying psychologic disorder
necessitating antipsychotics and biperiden. She
was not lactating. Ultrasonography revealed a
large retroareolar abscess measuring 8 centime-
ters in diameter. Abscess drainage with abscess
wall biopsy was performed under general anes-
thesia. It resembled malignant but on patholog-
ic examination, granulomatous perilobular
mastitis was reported. The patient suffered a de-
layed infection and recurrent contralateral
breast abscess formation which was treated by
recurrent aspirations. Abscess discharge cul-
ture was negative for acid fast bacilli(AFB) and
polymerase chain reaction (PCR) confirmutory
test was also negative. Discharge culture how-
ever, reveald  nonspecific bacterial growth.             
Case 2: 
A 34-year-old woman with a history of nor-
mal vaginal delivery at the age of 29, was re-
ferred because of a tender mass accompanying
a sense of heaviness in her right breast. She was
not lactating and there was no history of oral
contraceptive (OCP) consumption. She had a
history of taking levothyroxine for 15 years be-
fore admission because of a benign goiter be-
sides taking antipsychotic agents. On ultra-
sonography, the mass was detected as solid and
heterogenous in echo pattern and on mammog-
raphy, a hyperdense mass with irregular board-
ers suspected of infiltrative malignancy. On
pathologic tissue evaluation, chronic mastitis
with granulomatous changes was reported. Af-
terwards, the patient developed wound infec-
tion with significant suppurative discharge and
finally a chronic sinus was formed that lasted
nearly 2 months to resolve. Direct smear was
negative for AFB and PCR did not confirm tu-
berculosis. Considering our area as  endemic
for tuberculosis and presence of granulomata
on microscopic evaluation, empiric antituber-
culous treatment was accomplished but no clin-
ical improvment evidenced. During medical
MJIRI.Vol. 23, No.4, February 2010. pp. 233-237234
Idiopathic granulomatous mastitis
therapy, breast masses with sonographic fea-
tures suspected of malignancy were detected
but pathologic evaluation resulted in the same
diagnosis. Afterwards, the patient was fol-
lowed-up, for her condition.                                              
Case 3: 
A24-year-old girl was referred with left peri-
areolar breast abscess. On examination, the
whole breast was indurated and inflamed.
Sonographically, the abscess was confirmed.
Hence, surgical drainage was done and a biopsy
was taken from the inflamed abscess wall but
revealed granulomatous mastitis. Tissue smear
and culture for AFB was negative. There was a
history of convulsive disorder and antiepileptic
agent (eg. phenytoin & valproate sodium) con-
sumption since childhood. Following abscess
drainage, a suppurative sinus complicated the
surgical site and it took a long time to be healed.
In less than 6 months, the breast abscess re-
curred and was managed by needle aspiration.      
Discussion
Granulomatous mastitis was first described
by Kessler & Wolloch in 1972.
They reported 5 cases with the initial diagno-
sis of malignant breast mass who developed re-
current abscess formation containing granulo-
mata subsequently. They emphasized that this
rare disorder had a tendency to recur chronical-
ly [5].
Other systemic granulomatous disorders like
Wegener's granulomatosis or sarcoidosis must
be ruled out to establish the final diagnosis of
granulomatous mastitis[3,4]. In primary granu-
lomatous mastitis, the inflammatory process is
confined to breast lobules and microabscesses
may occupy the whole lobule. Areas of necrosis
may also develop. Giant cells and non-caseous
epithelioid cells constitute the nonspecific
granulation tissue in granulomatous mastitis
and those composed of foreign body cells and
the Langhans' cells. In the center of the granulo-
mata,polymorphonuclear cells (PMNs) are
more frequent than other cells and duct ectasia
may be absent [1,3].
The most important granulomatous disorder
which must be differentiated is tuberculosis
(that is especially endemic in our country). In
all 3 of the aforementioned cases, tissue acid
fast staining and the PCR test were negative for
tuberculosis. It is noteworthy that we did not
find any caseating necrosis (the key point to de-
235MJIRI.Vol. 23, No.4, February 2010. pp. 233-237
F. Ebrahimi-Fard, et al.
Fig. 1. Photomicrograph shows completely affected
breast lobules by chronic inflammation and granuloma-
tous formation. (Hematoxylin and eosin; magnification ×
100.)
Fig. 2. A mediolateral view of the right  breast showing
a large asymmetrical increased density in the upper outer
quadrant extending to the retroareolar region. Excisional
biopsy showed idiopathic granulomatous mastitis. 
termine tuberculosis) in our tissue specimens.
In all suspected cases, inflammatory carcinoma
must be ruled out; especially because it affects
nonlactating women. Hence, pathologic evalu-
ation of the lesion is strongly suggested.
The Granulomatous mastitis etiology is un-
known, and more common in young women.
No correlation between breast feeding or OCP
consumption and the mentioned disorder has
been found so far. Kessler & Wolloch have sup-
ported the autoimmune etiology mostly be-
cause microscopic features are similar to other
granulomatous disorders (like granulomatous
thyroiditis or orchitis).
Treatment of the granulomatous mastitis is
controversial [12]. Surgery is not abruptly ben-
eficial and in most of cases, simple drainage
and incisional biopsy are adequate [8]. De-
Hertogh and colleagues showed that short
courses of high dose prednisolone was efficient
although the follow-up period was shorter to
precisely evaluate recurrence rate [12].
In several studies, the diagnostic accuracy of
FNAhas been reported as 87-90%.
The aforementioned cases of granulomatous
MJIRI.Vol. 23, No.4, February 2010. pp. 233-237236
Idiopathic granulomatous mastitis
Fig.3. View of the left breast in a GM patient.
Fig. 4. (A) A case of idiopathic granulomatous mastitis showing chronic inflammation and noncaseating granulomas,
centered on breast lobules, which have been diffusely obliterated (hematoxylin-eosin; magnification ×100).  (B) Note the
presence of epithelioid histiocytes, lymphocytes, plasma cells, polymorph nuclear leukocytes, and multinucleated Lang-
hans-type giant cells (hematoxylin-eosin; magnification ×250).
mastitis who all presented with distinct clinical
features of the disease, are characteristic exam-
ples of clinical diagnostic pitfalls and the neces-
sity of histologic diagnosis to rule out other be-
nign and malignant pathologies of the breast. 
Granulomatous mastitis predominantly oc-
curs in nonlactating women [3,4], so, it is more
probable to assume the clinical feature as a ma-
lignant process [1,2,3], rather than an inflam-
matory disorder like mastitis or breast abscess.
It must be considered as a rare differential diag-
nosis (but not the first one) in breast especialists
approach.
Conservative and symptomatic treatment
should follow the surgical one at least to defini-
tively diagnose the disorder and rule out the dif-
ferential ones. Medical treatments such as
steroids or methotraxate, are under survey
[1,8,12]. The probability of drug resistance, re-
currence of the disease after drug discontinua-
tion and the risk of drug side effects should be
considered when medical therapy is selected
[8,11].
By reviewing the literature, granulomatous
mastitis is more common in Eastern countries
like China and Turkey where it can be epidemi-
ologically significant.Performing similar stud-
ies in Iran can also be helpful.
In addition, in all 3 cases of this paper, there
was a history of psychoactive drug consump-
tion that can be noteworthy but further studies
with a larger sample-size are required to deter-
mine the probable correlation.As a whole,more
clear evidence is needed to reveal its pathogen-
esis.
Conclusion
It is necessary to consider granulomatous
mastitis as a rare differential diagnosis from
other pathologies and not the first one. More
common benign and especially malignant dis-
orders of the breast should be ruled out prior to
making a definite diagnosis. 
References
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F. Ebrahimi-Fard, et al.


Idiopathic granulomatous mastitis: report of 3 cases and a review of the literature

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Idiopathic granulomatous mastitis: report of 3 cases and a review of the literature

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