Endgames Case Review

Sudden onset diffuse erythema and oedema of the breast

BMJ 2015; 351 doi: http://dx.doi.org/10.1136/bmj.h4166 (Published 06 August 2015) Cite this as: BMJ 2015;351:h4166
  1. Inês Vasconcelos, fourth year obstetrics and gynaecology resident1,
  2. Miguel de Sousa Mendes, second year obstetrics and gynaecology resident2,
  3. Jörg Linke, pathology consultant3,
  4. Winfried Schoenegg, obstetrics and gynaecology, breast surgery consultant1
  1. 1Berlin Breast Centre Kurfürstendamm, 10719 Berlin, Germany
  2. 2Vivantes Hospital, Neukölln, Berlin
  3. 3German Federal Armed Forces Pathology Practice, Berlin
  1. Correspondence to: I Vasconcelos ines.mv{at}gmail.com

A 40 year old premenopausal white woman presented to a general gynaecologist with diffuse redness, swelling, and rapidly progressive pain in her left breast. She did not have a fever. Her medical history included one full term pregnancy with spontaneous delivery 19 years earlier. Her maternal grandmother had died of breast cancer at age 65 years. On physical examination, a warm and painful diffuse oedematous erythema was found in the inner quadrants of the breast (fig 1), but she was otherwise in good general health.

Questions

  • 1. On the basis of the history and examination findings, what are the differential diagnoses and the probable diagnosis?

  • 2. What investigation(s) would you undertake to confirm your diagnosis?

  • 3. What is the optimal treatment for this condition?

Answers

1. On the basis of the history and examination findings, what are the differential diagnoses and the probable diagnosis?

Short answer

Non-lactational mastitis, cellulitis, abscess, and inflammatory breast cancer (IBC). Figure 1 shows a classic presentation of IBC.

Discussion

Breast masses require triple test evaluation—physical examination, radiological examination, and needle biopsy—the results of which must all agree. IBC is diagnosed on clinical grounds, so the physical examination is key. The classic findings are diffuse erythema and oedema with bulging intradermal lymphatics enveloping more than a third of the breast, as well as the absence of systemic symptoms such as malaise and fever.

The differential diagnosis in this setting, based on the physical examination, includes non-lactational mastitis, cellulitis, abscess, and inflammatory breast cancer. Non-lactational abscesses …

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