Necrotizing fasciitis is an uncommon and rapidly progressive, life-threatening soft tissue infection. Necrotizing fasciitis of breast is even rarely encountered. We managed one such 32 years old
nondiabetic, obese lady who developed necrotising fascitis of right breast after lumpectomy. Management involved wide debridement, antibiotics and wound care

Rather, AA

Salati, SA

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  ISSN 2073COSECSA/ASEA Publication    -East and Central African Journal of Surgery.  July/August 2012 Volume  Necrotizing fasciitis of breast  S.A. Salati1, A.A. Rather2 1College of Medicine, Qassim   University , Saudi Arabia2SK Instt of Medical Sciences (Medical College)SrinagarCorrespondence to: Dr Sajad Ahmad Salati, Email: docsajad@ Necrotizing fasciitis is an uncommon and rapidly progressive, lifeNecrotizing fasciitis of breast is even rarely encountered. We managed one such 32 years old nondiabetic, obese lady who developed necrotising fascitis of right breast after lumpectomy. Management involved wide debridement, antibiotics and wound care. Case Report  A 32 years old female reported after eight hours of having undergone excision of luquadrant of  right breast. The patient had felt reddish discoloration and increasing pain of the right breast after 2-3 hours of the procedure.  The patient had no significant past medical or surgical history. On examination, the patient was uncomfortablepulse of 114/minute. There was erythema and warmth over the upper inner and outer quadrants of right breast with marked tenderness.His BMI was 33.33 .  The laboratory paramhaemoglobin of 10.4mg/dl,  leucocytosis ( WBC count eosinophils 2%,) , C- reactive protein level of 124mg/dl, normal serum Sodium and potassum. The  random blood sugar level was 1071.2mg/dl.    The patient was started on intravenous antibiotics and analgesic but even after 10 hours , there was  no relief in symptoms and the  tender area over the breast increased . Sonogrechogenicity of the  fatty tissue with multiple small fluid collections in deeper tissues . MRI study was planned but the patient could not afford it as it had to be done in private sector  due to non availabilty in the hospital and hence it was decided to explore the breast under general anesthesia . A wide incision was made over the area of maximal tenderness and erythema. The sternal fascia was found to be necrotic and there was a copious greyish foul smelling, dishwater pus. The and the overlying breast parenchyma was viable and therefore preserved. ( Fig 1) Necrotising fasciitis was diagnosed on the basis of these operative findings.   Figure 1. Necrotic Fascia with Minimal Bleeding and92 -9990   East Cent. Afr. J. surg. (Online)  17 (2)  gmail.com -threatening  soft tissue infection.  mp in the left upper  due to pain, was febrile with a temperature of 38.2 eters on admission showed  a – 14200/cc with Polys 79%, lympocytes 19% and  mg/dl and The blood urea was 11mg/dl) and serum creatinine was aphy revealed increased underlying pectoralis muscle was healthy    Healthy Pectoral Muscles      0 C  and a  93   ISSN 2073-9990   East Cent. Afr. J. surg. (Online)   COSECSA/ASEA Publication    -East and Central African Journal of Surgery.  July/August 2012 Volume 17 (2)       The necrotic fascia, nonviable skin, and subcutaneous tissue were excised completely. After twentyfour hours , a second look  exploration under  general anesthesia did not reveal any further progression of disease and the wound was further managed with regular dressings and antibiotics were administered on the basis of microbiological analysis of the pus which grew streptocoocus pyogenes and E.coli. Healing occurred by secondary intention leaving a depressed scar about 4 cms in length. The histopathology report of the excised lump  did not reveal  features of fibroadenoma or carcinoma.  Discussion  Necrotising fasciitis is an uncommon infection of subcutaneous tissue and superficial fascia  that is associated with systemic toxicity , fulminant course  and high mortality and long term morbidity rates1. Necrotising fasciitis can occur after surgical procedures, minor trauma, in the setting of a chronic wound , drug injections or may occur spontaneously2. It is often associated with advanced age, chronic renal failure, obesity, malnutrition, alcoholism, postpartum state, steroid intake, immune-compromise, peripheral vascular disease or diabetes3 but may be initiated in an otherwise healthy person.  A number of bacteria in isolation or as a polymicrobial infection can cause this condition4. The microbes most closely linked to necrotising fasciitis are group A beta-hemolytic streptococci, although the disease may also be caused by other bacteria like enterobacteriaceae  or different streptococcal serotypes. Necrotising fasciitis of the breast is a rare entity and only a few cases have been  reported in the literature2,5-9. The most consistent feature is pain out of proportion to the visible local signs like erythema and warmth, as was the presentation  in our case. The disease usually gets initiated by some surgical intervention like biopsy and due to paucity of signs, may get misdiagnosed as cellulitis, abscess or even as a carcinoma. In our case, cyst aspiration  had trigerred this condition and obesity was the only identifiable comorbidity. As far as the diagnosis is concerned, the key factor lies in awareness and early suspicion of this condition. Imaging modalities like ultrasonography and MRI can aid in reaching the diagnosis9-10.  Treatment is wide  and earliest possible debridement with parenteral antibiotics . Cases getting diagnosed later may require  mastectomy but if condition is managed early, breast can be salvaged due to its robust blood supply10,11.  Acknowledgement  We acknowledge with thanks the cooperation of our patient for allowing us to  publish this case report and the  accompanying images.   References 1. Rieger UM, Gugger CY, Farhadi J, Heider I, Andresen R, Pierer G, Scheufler O. Prognostic factors in necrotizing fasciitis and myositis: analysis of 16 consecutive cases at a single institution in Switzerland. Ann Plast Surg. 2007; 58:523–30. 2. Subramanian A, Thomas G, Lawn A, Jackson P, Layer GT. Necrotising soft tissue infection following mastectomy. JSCR. 2010; 1:4 3. Taviloglu K, Yanar H. Necrotizing fasciitis: strategies for diagnosis and management. World J Emerg Surg. 2007; 2:19 4.  Kihiczak GG, Schwartz RA, Kapila R. Necrotizing fasciitis: a deadly infection. J Eur Acad Dermatol Venereol. 2006; 20(4):365-69 5. Shah J, Sharma AK, O'Donoghue JM, Mearns B, Johri A, Thomas V.  Necrotising fasciitis of the breast. Br J Plast Surg. 2001; 54(1):67-68 94   ISSN 2073-9990   East Cent. Afr. J. surg. (Online)   COSECSA/ASEA Publication    -East and Central African Journal of Surgery.  July/August 2012 Volume 17 (2)      6. Rajakannu, M., Kate, V., Ananthakrishnan, N. Necrotizing infection of the breast mimicking carcinoma. Breast J. 2006; 12(3):266-67  7.  Nizami, S., Mohiuddin, K., Mohsin-e-Azam, Zafar, H., Memon, M. A. Necrotizing fasciitis of the breast. Breast J. 2006; 12(2):168- 69  8. Flandrin A, Rouleau C, Azar CC, Dubon O, Giacalone PL. First report of a necrotising fasciitis of the breast following a core needle biopsy. Breast J. 2009; 15(2):199-201.  9. Wronski M, Slodkowski M, Cebulski W, Karkocha D, Krasnodebski IW Necrotizing fasciitis: early sonographic diagnosis. J Clin Ultrasound. 2011; 39(4):236-39 10. Wong, Chin-Ho, Tan, Bien-Keem. Necrotizing fasciitis of the breast. PRS 2008 ; 122(5):151e-152e  11. Soliman MO, Ayyash EH, Aldahham A, Asfar S. Necrotizing fasciitis of the breast: A case managed without mastectomy. Med Princ Pract 2011; 20:567-69   

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Necrotizing fasciitis of breast

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Necrotizing fasciitis of breast

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