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CASE REPORTS
SALMONELLA TYPHI IN BREAST ABSCESS
ROOPA VISWANATHAN*, ABHIDHA H SHAH**, LF NAGORI***, MK GUPTA****
Breast abscess in a non-lactating female must be evaluated for an underlying generalized disease as can be seen in this case report where Salmonella typhi was isolated.
INTRODUCTION
Enteric fever and gastroenteritis are generally associated with Salmonella typhi. Pyogenic infections due to Salmonella typhi have also been documented. We herewith report a rare case of Salmonella typhi induced breast abscess.
CASE REPORT
A 42 year old married non-lactating female noticed a swelling about 15 days before she presented to us. She gave a history of high grade fever and malaise prior to the swelling in the breast. There was gradual increase in the size of the swelling with minimal pain and no discharge from the nipple. There was no past history of any breast disease. She had no loose motions, constipation or urinary abnormality nor had she taken any TAB vaccination.
She gives no history of Tuberculosis or Tuberculosis contact. She was multiparous, non-lactating at the time of presentation and she had no menstrual irregularities.
There was no family history of any breast disease.
On general examination, the patient was afebrile and her other vital parameters were stable. On local examination, there was a single firm swelling 5 cm x 6 cm x 5 cm in size in the upper outer quadrant of the right breast, minimally tender, mobile, nonadherent to the skin. The skin over the swelling was normal but minimal dilated veins were seen. There was no discharge from the nipple and the areola was normal. Central group of the right axillary lymph nodes were palpable. The left breast had a small swelling about 2 cm x 1 cm in size. The left axilla was normal.
The respiratory, alimentary, nervous and musculoskeletal systems showed no abnormality.
The differential diagnosis rested between chronic abscess and primary carcinoma of the breast.
Diagnostic aspiration was done by 21 no. gauged needle. About 10 ml of greenish pus was aspirated. It was sent for culture and sensitivity. The patient was then started on Amoxycillin and Clavulinic acid combination.
Investigations were : Haemoglobin - 11.2 gm%, WBC - 7500 (59% neutrophils). Culture and sensitivity testing showed a pure growth of Salmonella typhi sensitive to Ciprofloxacin, Ofloxacin, Norfloxacin, Ceftizoxime, Cefuroxime, Ceftazidime, Cefaclor, Amikacin, Gentamycin, Netilmycin, Tobramycin, Piperacillin, Amoxycillin, Amoxycillin+Clavulinic acid, Ampicillin+Sulbactum, Cotrimoxazole and Chloramphenicol.
Widal test showed titres of Salmonella typhi H 1 : 120, 0
1 : 120. Titres of Salmonella paratyphi A and paratyphi B were nil. Blood culture showed no growth. Urine and stool cultures yielded no pathogenic organism. Biochemistry, Chest X-ray, ECG were all normal.
Mammography done at the time of discovery of the swelling showed 2 cysts in the right breast measuring 2.4 cm x 1.9 cm each and a cyst in left breast measuring 3.0 cm x 1.1 cm.
USG done at the same time also showed 2.1 cm x 1 cm and 3.5 cm x 1.2 cm cysts in the right and left breasts respectively.
USG abdomen and pelvis showed no abnormality.
The patient was treated conservatively with tablet Ciprofloxacin (500 mg) twice daily for 14 days whereby the cyst size decreased and she had no fever and no systemic complaints.
Repeat aspiration sent for culture showed no growth. On subsequent examination, there was no further decrease in the size of the cyst. Hence it was surgically excised. The specimen yielded no growth in culture. Histological section of the wall of the abscess showed chronic inflammation.
DISCUSSION
The incidence of mastitis in typhoid patients has been given as 0.3% in 1930 by Klose and Sebening and 0.5% in 1937 by Pezinski in a study of 1,196 cases of typhoid over a period of 2 years. In females, the incidence was 0.9%.1 A typhoid breast abscess was defined as one which arose in a case of generalized disease with difficulty in isolating the organism and constant findings of WBC count below 13000/mm3. It is a late complication due to physiologic breast activity.
Madelung (1923) and Erbosloh (1954) suggested that the isolation of the pure Salmonella typhi from breast abscess was impossible.1 But in present case and in another case reported by Barrett et al (1972)1, isolation of Salmonella typhi from breast abscess material was possible.
Staphylococcus aureus, Staphylococcus epidermidis, Streptococcus spp., Bacteroides etc have been responsible for breast abscess in a hospital.2 Razeq et al (2000)3 and Edelstein (1993)4 have implicated Salmonella enterica serotype Landweisser and Salmonella serogroup B in breast abscess respectively. In present case, besides fever, which could be also a feature of breast abscess, there has been no other manifestation of typhoid. The pure isolation of Salmonella typhi in culture from the breast aspirate along with the WBC count of 7500/cmm with significant Widal titres were the only factors going in favour of breast abscess in typhoid.
The patient responded to the oral Ciprofloxacin which reduced the swelling and killed the organism yielding no growth in subsequent cultures. The reduced swelling was then surgically excised. Thus both medical and surgical modalities of treatment were used in this case.
Kumar (1998)5 reported a multidrug resistant typhoid with breast abscess. In present case however the isolate of Salmonella typhi showed good susceptibility to most drugs as mentioned before.
In conclusion, any breast abscess in a non-lactating female with no other predisposing factors must be evaluated for an underlying generalized disease and the pus aspirated or drained must be sent for culture and sensitivity. If not done, such a diagnosis could be easily missed. Also, a combination of medical and surgical management may help in such a case.
ACKNOWLEDGEMENT
We would like to acknowledge the quality consciousness and perseverance for excellence of the technical staff of microbiology section of the Bombay Hospital without whom, this paper would not have been possible - Mr. Rao, Mr. Rodrigus, Mr. Harikumar, Mr. Bhoir, Mr. Shelar, Mr. Parab and Mr. Yadav.
REFERENCES
1. Barrett GS, MacDermott John. Breast abscess : A rare presentation of typhoid. Br Med J 1972; 2 (814) : 628-9.
2. Schoelefield JH, Duncan JL, Rogers K. Review of a hospital experience of breast abscesses. Br J Surg 1987;74:469-70.
3. Razeq J, Glenn A, Thomas G, Sholes A. First human case of Salmonella enterica Serotype, Landweisser recovered from breast fluid. J Clin Microbiol 2000; 38 (11) : 4300.
4. Edelstlein H. Breast abscess due to Salmonella Serogroup B, serotype reading in a young non-lactating puerperal woman. Clin Infect D 1993; 17 (15) : 951-2.
5. Kumar PD. Breast abscess : a rare complication of multirestistant typhoid fever. Trop Doct 1998;4:238-9.
