On examination she had no fever and an extremely tender mass about 10×6 cm that could be palpated on the base of her left breast. There were around four fistulas around her areola, which discharged yellowish granular pus when pressuring the breast (). We could also see many healed scars around her areola.
Photograph of breasts showing several pus-filled fistulas of the left breast.
Her laboratory results were erythrocyte sedimentation rate 70 mm/h, C reactive protein 74 mg/l, haemoglobin 6.8 mmol/l, white blood cells 40×109/l (differentiation: eosinophils 2×109/l, neutrophils 53×109/l, lymphocytes 37×109/l, monocytes 8×109/l), creatinine 62 µmol/l, angiotensin converting enzyme level 12 U/l, aspartate transaminase 18 U/l, alanine transaminase 11 U/l and bilirubin 4 µmol/l. Microscopic examination of the urine was normal. Antinuclear antibodies were negative, classical antineutrophil; cytoplasmic antibodies were negative; rheumatoid factor was negative; and anticyclic citrullinated peptide was negative.
An ultrasound-guided needle aspiration was performed and histopathology showed a granulomatous inflammation with large numbers of neutrophils and multinucleated giant cells. No acid-resistant rods were found. Repeated cultures of the pus showed no growth. PCR for Mycobacterium tuberculosis, Norcadia, actinomycosis and eubacterial-PCR were negative.
An ultrasound examination showed an inhomogeneous hypoechoic mass located mostly at the left upper quadrant but spread over the whole breast with multiple cavities filled with a fluctuating fluid—possibly pus. A T1-weighted MRI of the breast was made and an extensive mastitis was seen. There were several well-defined pus collections and fitful staining implying malignant disease. Mammography comparing left to right showed an irregular parenchyma at the left side and some nodular thickening. At the right side there were no abnormalities.