Actinomyces europaeus was first described in 1997 as a new species causing predominantly skin and soft-tissue infections. Mastitis due to A. europaeus is an unusual condition. This article reports a case of primary breast abscess caused by A. europaeus in a postmenopausal woma

Bögli-Stuber, K.

Droz, S.

Jahns, B.

Pinheiro, A.

Silva, W.

Zimmerli, S.

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CASE REPORTBreast abscess due to Actinomyces europaeusW. A. Silva • A. M. Pinheiro • B. Jahns • K. Bo¨gli-Stuber • S. Droz •S. ZimmerliReceived: 24 January 2011 / Accepted: 31 March 2011 / Published online: 21 April 2011 Springer-Verlag 2011Abstract Actinomyces europaeus was first described in1997 as a new species causing predominantly skin and soft-tissue infections. Mastitis due to A. europaeus is an unusualcondition. This article reports a case of primary breastabscess caused by A. europaeus in a postmenopausal woman.Keywords Actinomyces europaeus  Actinomycosis MastitisIntroductionActinomyces spp. normally colonizes mucous membranesparticularly of the oral cavity, the colon, and the vagina.Disruption of the mucosa may lead to indolent infectionscharacterized by a chronic course, progression across tissueboundaries, and formation of sinus tracts. Until recently,identification of Actinomyces spp. was based on phenotypictests. With increasing use of genotypic analysis taxonomyhas advanced and new species have been described in thepast 15 years. The disease-causing potential of many ofthese newly described species and the associated range ofclinical manifestations is, however, incompletelyunderstood.A. europaeus is a Gram-positive, nonmotile, non-spore-forming facultative anaerobic rod first described as newspecies in 1997 on the basis of 16S rRNA gene sequencing[1]. It was found to cause infections of the urinary tract andof skin and soft-tissue, notably abscesses, pilonidal sinusinfection, and decubital ulcers [2]. In this article we reporta case of primary breast abscess caused by A. europaeus ina postmenopausal woman.Case reportA 67-year-old immunocompetent woman was admitted tothe hospital because of a painful swelling and hyperemia ofthe left breast which had appeared 3 days earlier. Therewas no history of fever, nipple discharge, tooth problems,or lung or breast disease. She was not diabetic and was anon-smoker. Two months earlier, she had undergoneuncomplicated open heart surgery to receive a prostheticaortic valve for severe aortic stenosis.On physical examination, the patient was afebrile andthere were no signs of systemic disease. Her body massindex was 28.9 kg/m2. There was a tender, fluctuating massof 12 cm in the left breast. The overlying skin was infil-trated and erythematous. The margin of the inflamed skinW. A. Silva  A. M. PinheiroFederal University of Rio Grande do Norte,University Hospital Onofre Lopes, Nilo Pec¸anha avenue 620,P.O. Box 59012-300, Natal, RN, Brazile-mail: wallaceandrino@yahoo.com.brA. M. Pinheiroe-mail: aline_mpinheiro@yahoo.com.brB. JahnsClinic for Gynecology, Inselspital, University Hospitaland University of Bern, Freiburgstr. 3, 3010 Bern, Switzerlande-mail: boriana.jahns@insel.chK. Bo¨gli-Stuber  S. Droz  S. Zimmerli (&)Institute for Infectious Diseases, University of Bern,Friedbuehlstr. 51, P.O. Box 61, 3010 Bern, Switzerlande-mail: stefan.zimmerli@ifik.unibe.chS. Droze-mail: sara.droz@ifik.unibe.chPresent Address:K. Bo¨gli-StuberSwissmedic, Hallerstrasse 7, 3000 Bern 9, Switzerlande-mail: katja.boegli@swissmedic.chInfection (2011) 39:255–258DOI 10.1007/s15010-011-0119-3reached within 2 cm of the sternotomy scar which waswithout signs of inflammation. Sternal compression wasnot painful.Results of laboratory tests showed a hemoglobin level of114 g/L, a WBC of 12.3 G/L without a left shift, athrombocyte count of 117 G/L, and a level of C-reactiveprotein of 35 mg/L. A chest X-ray was normal and acomputed tomography scan of the thorax showed no signsof infection of the sternum or of intrathoracic tissues.Blood cultures were negative. The clinically diagnosedbreast abscess was incised and drained under generalanesthesia. Pus and tissue samples were sent for microbi-ological examination and for histopathology. Postopera-tively there was a tender mass of 12 9 6 cm in the inferiorhalf of the breast. The wound was left open and a drainagetube was inserted. Two days later, the patient was free frompain and was discharged on oral amoxicillin-clavulanicacid 1 g tid.Histopathology showed adipose-tissue necrosis, no sul-fur granules, and no evidence of malignancy. Gram stainsof pus revealed many Gram-negative bacilli and Gram-positive rods. Again, no sulfur granules were seen. Culturesgrew Actinomyces spp. and a mixed anaerobic flora com-posed of Gram-negative rods and Gram-positive cocci thatwas not further characterized. A. europaeus was identifiedby full-length sequencing of the 16S rRNA gene by usingMicroSeq Full Gene 16S rDNA PCR and sequencing kits(Applied Biosystems). BLAST analysis showed 99.7%identity with the 16S rRNA gene sequence of A. europaeusstrain CCUG 32789A (GenBank accession no.NR_026363). The isolate was tested for susceptibilityusing the E test (AB Biodisk, Solna, Sweden) with thefollowing results: penicillin G MIC: 0.008 lg/mL, amox-icillin MIC: 0.023 lg/mL, ceftriaxone MIC: 0.047 lg/mL,piperacillin-tazobactam MIC: 0.047 lg/mL, clindamycinMIC: 0.016 lg/mL, and tetracycline MIC: 0.380 lg/mL.According to the Clinical and Laboratory Standards Insti-tute criteria the isolate was susceptible to all tested anti-microbial agents [3].After three weeks, under the assumption that the mixedanaerobic flora had been eliminated, treatment waschanged to amoxicillin 2 g tid for 4 weeks followed byamoxicillin 1 g tid for the remainder of the treatmentperiod. The breast remained non-tender and painless. Thetissue mass, infiltrated skin, and wound secretionsimproved only very slowly. After three months, threedraining sinuses secreting minimal amounts of pusdeveloped on the inferior aspect of the breast (Fig. 1).The opening left by the abscess drainage healed bygranulation after 10 months. The draining sinuses thatwere de´brided regularly resolved after 15 months. At thattime the antibiotic treatment was discontinued. At follow-up, 6 months later, there were no signs of recurrentinfection; the breast was free of masses and its shape wasonly minimally altered by scar formation.DiscussionThe main clinical manifestations of actinomycosis areslowly progressing, granulomatous and sinus-forminginfections in the cervicofacial, thoracic, abdominal, and, inwomen, pelvic areas. Adjacent organs may be infiltratedbut hematogenous dissemination has not been observed.The disease is four times more common in men; usuallypatients are in good health, free from underlying diseases[4].Breast infections are relatively common, particularly inlactating women. They are often caused by bacteria ofnormal skin or oral flora, especially Staphylococcus aureus.Breast infections with Actinomyces spp. are rare and havemainly been described in premenopausal women [5]. Theyare classified as primary or secondary, depending on howthe microorganisms reach the site of infection. Secondaryactinomycosis of the breast results from pulmonary infec-tion penetrating through the thoracic wall [5, 6]. The morecommon primary form occurs when skin flora reachmammary tissue directly, possibly through cracks in theskin on or around the nipple. Risk factors for developmentof primary breast abscess include smoking, diabetes, andobesity [7]. Primary actinomycosis of the breast has mostcommonly been ascribed to A. israelii [4]. More recently,breast infections due to A. viscosus, A. turicensis, andA. radingae have been described [8, 9]. Seven of the tenFig. 1 Photograph of the patient’s left breast 6 months after abscessdrainage and start of antibiotic therapy. The incision wound on themedial aspect is healing, the mass in the inferior medial quadrant anderythematous skin have improved. On the inferior aspect drainingsinuses that formed after 3 months of antibiotic therapy are coveredby necrotic membranes that are regularly de´brided. Eventual healingwas observed after 15 months of treatment256 W. A. Silva et al.clinical strains in the first description of A. europaeus wereisolated from human abscesses, one of which was a breastabscess in a 54-year-old woman [1]. Interestingly, sulfurgranules have not been described in abscesses due to A.europaeus and were not found in this case [1, 2, 9].Absence of sulfur granules has also been observed ininfections caused by A. neuii, another Actinomyces speciesnot commonly associated with classical actinomycosis[10].The patient described here did not have pulmonarydisease or evidence of osteomyelitis of the sternum or theribs. It is plausible that actinomycetes reached mammarytissues through skin lacerations caused by post-sternotomydressings.Interestingly, the association of A. europaeus with otherbacteria is more common than its isolation in pure culture.Clarridge et al. [11] found them associated with coagulase-negative staphylococci and corynebacteria and suggestedthat the normal niche of A. europaeus was the skin of theupper body. Sabbe et al. [2] found A. europaeus accom-panied by a mixed anaerobic flora, as in the case describedhere. Attar et al. [8] also described two cases of actino-mycosis of the breast (caused by strains other than A. eu-ropaeus) in association with anaerobic bacteria.The most common clinical presentation of actinomy-cosis of the breast is recurrent retropapillary abscesses.Fistulas and purulent or bloody discharge from sinuses mayoccur. In the most advanced cases, fibrosis with local cic-atrisation and distortion of the breast were reported [4]. Inone series, two-thirds of the cases presented as persistent orrecurrent breast abscesses and the other third presentedwith a breast lump suggestive of carcinoma [12]. Furtherdifferential diagnoses include tuberculosis, syphilis, ribosteomyelitis, and inflammatory carcinoma [5].Recommended treatment for actinomycosis is intrave-nous penicillin at a daily dose of 18–24 million U for2–6 weeks, followed by oral penicillin or amoxicillin for aperiod of 6–12 months. Shorter treatment regimens mayalso be successful [13]. In the case presented here, how-ever, treatment was given for 15 months, until full closureof all skin lesions. All reported cases of Actinomyces spp.of the breast have been successfully treated with a com-bination of surgical drainage and short-course antibiotictherapy [8, 9]. Surgical curettage is an important adjunctivetreatment because of limited penetration of the antibioticsinto the chronically indurated tissue of actinomycoticlesions and the dense aggregates of Actinomyces spp.known as sulfur granules.A. europaeus seems to be susceptible in vitro to a widerange of b-lactam antibiotics which should be regarded asagents of first choice. Some A. europaeus have reducedsusceptibility to tetracycline, ciprofloxacin, clindamycin,linezolid, and piperacillin/tazobactam [14]. The isolatereported here was fully susceptible to all b-lactam agentstested, and to clindamycin and tetracycline. In mixedinfections with anaerobes amoxicillin–clavulanic acid maybe preferred for initial treatment because of the notable b-lactamase activity of certain anaerobes.Physicians and microbiologists should be aware that theclinical range of disease manifestations due to Actinomycesspp. may be widening and that new species may be causingparticular disease manifestations. Treatment should beindividualized and may need to be prolonged.Acknowledgment The study was made possible in part through acollaborative project financed by the UBS Optimus Foundation and aneducational research grant by Pfizer AG, Switzerland.Conflict of interest None.References1. Funke G, Alvarez N, Pascual C, Falsen E, Akervall E, Sabbe L,Schouls L, Weiss N, Collins MD. Actinomyces europaeus sp.nov., isolated from human clinical specimens. Int J Syst Bacte-riol. 1997;47:687–92.2. Sabbe LJ, Van De Merwe D, Schouls L, Bergmans A, Van-eechoutte M, Vandamme P. Clinical spectrum of infections dueto the newly described Actinomyces species A. turicensis, A.radingae, and A. europaeus. J Clin Microbiol. 1999;37:8–13.3. Clinical and Laboratory Standards Institute (2007) Methods forAntimicrobial Susceptibility Testing of Anaerobic Bacteria;Approved Standard- Seventh Edition. CLSI document M11-A7Clinical and Laboratory Standard Institute, Wayne, PA.4. Davies JA. Primary actinomycosis of the breast. Br J Surg.1951;38:378–81.5. de Barros N, Issa FK, Barros AC, D’Avila MS, Nisida AC,Chammas MC, Pinotti JA, Cerri GG. Imaging of primary acti-nomycosis of the breast. AJR Am J Roentgenol.2000;174:1784–6.6. Pinto MM, Longstreth GB, Khoury GM. Fine needle aspiration ofActinomyces infection of the breast. A novel presentation ofthoracopleural actinomycosis. Acta Cytol. 1991;35:409–11.7. Gollapalli V, Liao J, Dudakovic A, Sugg SL, Scott-Conner CE,Weigel RJ. Risk factors for development and recurrence of pri-mary breast abscesses. J Am Coll Surg. 2010;211:41–8.8. Attar KH, Waghorn D, Lyons M, Cunnick G. Rare species ofactinomyces as causative pathogens in breast abscess. Breast J.2007;13:501–5.9. Capobianco G, Dessole S, Becchere MP, Profili S, Cosmi E,Cherchi PL, Meloni GB. A rare case of primary actinomycosis ofthe breast caused by Actinomyces viscosus: diagnosis by fine-needle aspiration cytology under ultrasound guidance. Breast J.2005;11:57–9.10. von Graevenitz A: Actinomyces neuii: review of an unusualinfectious agent. Infection. 2011 Feb 22. [Epub ahead of print]PMID: 21340579.11. Clarridge JE 3rd, Zhang Q. Genotypic diversity of clinical Acti-nomyces species: phenotype, source, and disease correlationamong genospecies. J Clin Microbiol. 2002;40:3442–8.Actinomyces europaeus breast abscess 25712. Jain BK, Sehgal VN, Jagdish S, Ratnakar C, Smile SR. Primaryactinomycosis of the breast: a clinical review and a case report.J Dermatol. 1994;21:497–500.13. Sudhakar SS, Ross JJ. Short-term treatment of actinomycosis:two cases and a review. Clin Infect Dis. 2004;38:444–7.14. Smith AJ, Hall V, Thakker B, Gemmell CG. Antimicrobial sus-ceptibility testing of Actinomyces species with 12 antimicrobialagents. J Antimicrob Chemother. 2005;56:407–9.258 W. A. Silva et al.

Breast abscess due to Actinomyces europaeus

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Breast abscess due to Actinomyces europaeus

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