Abstract Introduction <it>Mycobacterium fortuitum </it>is a rapidly growing group of nontuberculous mycobacteria more common in patients with genetic or acquired causes of immune deficiency. There have been few published reports of <it>Mycobacterium fortuitum </it>associated with breast infections mainly associated with breast implant and reconstructive surgery. Case presentation We report a case of a 51-year-old Caucasian woman who presented to our one-stop breast clinic with a two-week history of left breast swelling and tenderness. Following triple assessment and subsequent incision and drainage of a breast abscess, the patient was diagnosed with <it>Mycobacterium fortuitum </it>and treated with antibiotic therapy and surgical debridement. Conclusion This is a rare case of a spontaneous breast abscess secondary to <it>Mycobacterium fortuitum </it>infection. Recommended treatment is long-term antibacterial therapy and surgical debridement for extensive infection or when implants are involved.</p

BA Brown

CG Lewis

DC Vinh

Dibendu Betal

DZ Uslan

Fiona A MacNeill

FJ Cooke

HW Clegg

J Haiavy

J Rimmer

PM Coney

R Patel

RJ Wallace Jr

W Butler

English

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CASE REPORT Open Access
Chronic breast abscess due to Mycobacterium
fortuitum: a case report
Dibendu Betal* and Fiona A MacNeill
Abstract
Introduction: Mycobacterium fortuitum is a rapidly growing group of nontuberculous mycobacteria more common
in patients with genetic or acquired causes of immune deficiency. There have been few published reports of
Mycobacterium fortuitum associated with breast infections mainly associated with breast implant and reconstructive
surgery.
Case presentation: We report a case of a 51-year-old Caucasian woman who presented to our one-stop breast
clinic with a two-week history of left breast swelling and tenderness. Following triple assessment and subsequent
incision and drainage of a breast abscess, the patient was diagnosed with Mycobacterium fortuitum and treated
with antibiotic therapy and surgical debridement.
Conclusion: This is a rare case of a spontaneous breast abscess secondary to Mycobacterium fortuitum infection.
Recommended treatment is long-term antibacterial therapy and surgical debridement for extensive infection or
when implants are involved.
Introduction
Mycobacterium fortuitum group is a rapidly growing
group of nontuberculous mycobacteria more common
in patients with genetic or acquired causes of immune
deficiency. There have been few published reports of
Mycobacterium fortuitum infection in connection with
breast infections mainly associated with breast implant
and reconstructive surgery. We describe a rare case of a
spontaneous breast abscess secondary to Mycobacterium
fortuitum infection. Recommended treatment is long-
term antibacterial therapy and surgical debridement for
extensive infection or when implants are involved.
Case presentation
A 51-year-old Caucasian woman, a professional musi-
cian, was referred to our one-stop breast clinic with a
two-week history of left breast swelling and tenderness
that started prior to her most recent menstrual period.
She menstruated regularly and had no previous history
of breast disease, and her grandmother had been diag-
nosed with breast cancer at age 78 years. She had an
eight-year-old daughter who was breast-fed for two
years and was a nonsmoker with no significant medical
history. Preceding presentation there was no history of
foreign travel, she was not taking any medications, and
she had experienced no trauma to the breast.
The clinical examination revealed redness, induration,
and swelling in the upper half of the breast extending to
the nipple. There was no nipple discharge, lymphadeno-
pathy, or pyrexia. Her mammogram was normal (M1),
and ultrasound revealed nonspecific inflammatory
changes with no focal lesions (U3). The clinical impres-
sion was of mastitis, but the picture was not typical of
periductal mastitis, which is more common in younger
women and smokers, nor was it typical of lactational
mastitis in breast-feeding women.
A core biopsy demonstrated chronic mastitis (B2) that
showed mixed inflammatory lobulitis with fat necrosis
and fibrosis, but no vasculitis. No microcalcification,
ductal carcinoma in situ, or invasive malignancy was
identified. Her blood tests (full blood count, renal func-
tion, liver function, thyroid function, and blood glucose)
were all within normal limits.
She was treated initially with oral flucloxacillin 500 mg
four times daily and then switched to co-amoxiclav 625
mg three times daily. After the core biopsy, her breast
appearance deteriorated, with worsening swelling,
* Correspondence: ulogin2000@yahoo.co.uk
Academic Surgery (Breast Unit), Royal Marsden NHS Foundation Trust,
Fulham Road, London, SW3 6JJ, UK
Betal and MacNeill Journal of Medical Case Reports 2011, 5:188
http://www.jmedicalcasereports.com/content/5/1/188 JOURNAL OF MEDICAL
CASE REPORTS
© 2011 Betal and MacNeill; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
induration, cellulitis, and discharging sinus despite two-
week oral antibiotic treatment. Fluid from the sinus was
cultured, and there was no bacterial growth or any evi-
dence of methicillin-resistant Staphylococcus aureus.
The microbiologist at our clinic recommended intrave-
nous antibiotic therapy; however, because of the
patient’s professional and social commitments, it was
not practical for her to be admitted as an inpatient. She
was commenced on a higher dose of oral flucloxacillin,
1 g three times daily.
Three weeks after her initial presentation a deep col-
lection became apparent, with pointing on the skin sur-
face. Repeat ultrasound of the left breast confirmed two
loculated collections. She was not keen on undergoing
any surgical intervention, so outpatient incision and
drainage were performed. Specimens were sent for rou-
tine bacteriology, acid-fast bacteria stain, Gram stain,
and fungal stains and culture. Her pus culture was
found to be sterile on routine bacterial culture, so the
possibility of an atypical infection such as mycobacter-
ium process was considered and she was started on
intravenous flucloxacillin 500 mg four times daily and
oral rifampicin 300 mg twice daily.
After another two weeks of treatment, the cellulitis in
her left breast had improved, but the breast remained
swollen, with multiple sinuses near the nipple. Further
ultrasound of the left breast demonstrated multilocu-
lated abscesses. Five weeks after her initial presentation,
the patient underwent surgical incision and drainage
through the inframammary crease with placement of a
small drain to allow gravity-dependent drainage. Repeat
histology showed granulomata formation and chronic
mastitis with no evidence of malignancy. The initial dif-
ferential diagnosis included nocardia or Actinomyces
infection. Subsequent submitted specimens identified
Mycobacterium fortuitum complex as the causative
agent.
After eight weeks of antibiotic therapy with doxycyline
100 mg twice daily and ciprofloxacin 500 mg twice
daily, her breast improved clinically. The patient had no
further recurrence of the infection and was discharged
from our outpatient clinic six months later.
Discussion
Mycobacterium fortuitum is a rapidly growing group of
mycobacteria not encompassing Mycobacterium tuber-
culosis, which has been implicated as a cause of pul-
monary, soft tissue, and disseminated infections.
Mycobacterium fortuitum is present in natural and
processed water sources as well as in sewage and soil.
It may show clinical signs following trauma or surgery
after contamination of the wound, medical device
implantation, and injection site abscesses. Dissemi-
nated disease is usually seen in patients who are
immunocompromised, such as individuals who are
human immunodeficiency virus-positive or have under-
gone a course of chemotherapy or corticosteroid treat-
ment [1]. Immune deficiency may be genetic as a
result of defects in the interleukin-12/interferon-g axis.
The true incidence of Mycobacterium fortuitum infec-
tion is unknown, but it has been estimated to be
between four to six cases per one million people [2].
There have been few published reports of Mycobacter-
ium fortuitum associated with breast infections. There
has been only one published report of spontaneous
breast abscess due to Mycobacterium fortuitum [3] and
another report following nipple piercing [4]. The major-
ity of papers have reported an association following
breast implant and reconstructive surgery [5-8].
If Mycobacterium complex is suspected as the source
of infection, antibacterial therapy should be commenced.
Previous publications regarding first-line antimicrobial
therapy for Mycobacterium fortuitum infection have
recommended amikacin, inipenem, fluoroquinolones,
cefoxitin, sulfonamides, and linezolid with variable sensi-
tivity to doxycycline and clarithromycin [9-12]. Many
reports have suggested success with single-agent treat-
ment, although combination therapy is recommended.
However, no standard duration of therapy is reported,
and treatment may last up to six months or more
[10,11].
Ultimately, the only cure for Mycobacterium fortuitum
infection may be surgical debridement, especially if the
infected area is extensive and the infection involves an
implant, which is normally removed [5-8].
Conclusion
This case highlights an unusual presentation of sponta-
neous breast infection. If there is no improvement of
breast infections despite standard antibiotic therapy, aty-
pical mycobacteria need to be considered as the causa-
tive pathogen. Recommended treatment is long-course
antibacterial therapy and possible surgical debridement
if the area is extensive and implants are involved.
Consent
Written informed consent was obtained from the patient
for publication of this case report and any accompany-
ing images. A copy of the written consent is available
for review by the Editor-in-Chief of this journal.
Authors’ contributions
DB wrote the paper, and FAM performed surgical procedure. Both authors
read and approved the final manuscript.
Competing interests
The authors declare that they have no competing interests.
Received: 4 May 2010 Accepted: 18 May 2011 Published: 18 May 2011
Betal and MacNeill Journal of Medical Case Reports 2011, 5:188
http://www.jmedicalcasereports.com/content/5/1/188
Page 2 of 3
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doi:10.1186/1752-1947-5-188
Cite this article as: Betal and MacNeill: Chronic breast abscess due to
Mycobacterium fortuitum: a case report. Journal of Medical Case Reports
2011 5:188.
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Chronic breast abscess due to Mycobacterium fortuitum: a case report

Abstract Introduction Mycobacterium fortuitum is a rapidly growing group of nontuberculous mycobacteria more common in patients with genetic or acquired causes of immune deficiency. There have been few published reports of Mycobacterium fortuitum associated with breast infections mainly associated with breast implant and reconstructive surgery. Case presentation We report a case of a 51-year-old Caucasian woman who presented to our one-stop breast clinic with a two-week history of left breast swelling and tenderness. Following triple assessment and subsequent incision and drainage of a breast abscess, the patient was diagnosed with Mycobacterium fortuitum and treated with antibiotic therapy and surgical debridement. Conclusion This is a rare case of a spontaneous breast abscess secondary to Mycobacterium fortuitum infection. Recommended treatment is long-term antibacterial therapy and surgical debridement for extensive infection or when implants are involved.</p

Chronic breast abscess due to Mycobacterium fortuitum: a case report

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