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Breast Disease 35 (2015) 33–36 DOI 10.3233/BD-140385 IOS Press

Case report

Bilateral eosinophilic mastitis: An uncommon unheard entity Aminder Singh∗ , Pavneet Kaur, Neena Sood, Harpreet Puri and Bhavna Garg Department of Pathology, Dayanand Medical College & Hospital, Tagore Nagar, Ludhiana, Punjab, India

Abstract. We are reporting a case of bilateral eosinophilic mastitis which is rare and hardly heard. It is a mimicker of carcinoma breast both clinically & radiologically. A 30 years old non diabetic female presented with bilateral breast lumps with history of rhinitis off & on and peripheral eosinophilia. Mammography was suspicious while ultrasonography was diagnostic of bilateral mastitis. Aspiration cytology exhibited inflammatory lesion rich in eosinophils. Histopathology revealed the diagnosis of eosinophilic mastitis. Eosinophilic infiltration of the breast is a rare manifestation of tissue involvement in peripheral eosinophilia and bilateralism is even rarer. Keywords: Eosinophilic mastitis, eosinophilia

1. Introduction Eosinophilic Mastitis is an uncommon entity with only few cases reported in literature, moreover, bilateral eosinophilic mastitis is almost not known. Eosinophilic infiltration of the breast is a rare manifestation of tissue involvement in peripheral eosinophilia. Clinical and radiological findings of these cases are nonspecific and can mimic breast carcinoma [1]. Diagnosis is difficult due to the rarity and non-specificity of the pathology. However, timely diagnosis based on history, clinical examination, radiology and cytology can prevent unnecessary surgery [1–4].

2. Case history A 30-year-old non diabetic female presented with bilateral breast lumps associated with mastalgia for the ∗ Corresponding author: Aminder Singh, Department of Pathology, Dayanand Medical College & Hospital, Tagore Nagar, Pathology, 0091-8968966550, Ludhiana, Punjab 141001, India. E-mail: [email protected].

last 3 months and bilateral nipple discharge. There was no history of fever/trauma/significant weight loss/loss of appetite/drug intake or family history of breast cancer. No symptoms suggestive of pulmonary and dermatological involvement were elicited except for history of allergic rhinitis on and off. She was lactating till one year back. A total leukocyte count of 16400/mm3 with 49% eosinophils on differential leucocyte count and absolute eosinophil count of 8000/mm3 was recorded. Her HIV, HBsAg and Anti HCV serology was negative. Ultrasonography revealed ill-defined heterogeneous predominantly hypoechoic areas in bilateral breast parenchyma more so in the retroareolar region with unorganized phlegmon formation and subcutaneous edema. Sub centimeter lymph nodes were seen in both axilla. Mammography revealed no discrete mass lesion because of the dense parenchymal pattern of the breast (Fig. 1). On local examination bilateral breast lumps were noted, the right lump (present in the retroareolar region) measured 4 × 3 cm while left (lower inner quadrant) measured 2 × 2 cm. Both lumps were irregular, non tender, firm with slight mobility and were not fixed to the overlying skin or underlying chest wall. Fine needle aspiration cytology showed cohesive clumps of benign epithelial cells, myoepithe-

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A. Singh et al. / Bilateral Eosinophilic Mastitis: An uncommon unheard entity

Fig. 1. Mammography both breasts revealed extremely dense parenchymal pattern and no discrete mass lesions were appreciated because of the dense breast. (Colours are visible in the online version of the article; http://dx.doi.org/10.3233/BD-140385)

lial cells with numerous inflammatory cells composed mainly of eosinophils admixed with few neutrophils, lymphocytes and macrophages against a necrotic background. No epithelioid cell granuloma or malignant cells were seen in the smears examined. A cytological diagnosis of Inflammatory Breast pathology was suggested with a comment to keep the patient on cytological follow up and repeat the aspiration if lesion persisted after therapy. Patient was put on antibiotics and underwent incision and drainage of the both lesions with incisional biopsy as the lesion did not respond to usual therapy. The drained pus was sent for culture and sensitivity but did not show any microbial growth. Histopathological evaluation from both breast lesions showed massive infiltration of eosinophilic granulocytes around ducts and lobules filled with intraluminal secretory material at places. The involved ducts and lobules display focal reactive epithelial changes with enlarged nuclei and prominent nucleoli thus confirming the diagnosis of Bilateral Eosinophilic Mastitis (Fig. 2).

3. Discussion Mastitis is an inflammatory condition of the breast, which may or may not be accompanied by infec-

tion [8]. Bilateral eosinophilic mastitis is an extremely rare clinico-pathological entity associated with peripheral eosinophilia, with little evidence regarding proper diagnosis and treatment modalities. It is considered to be a benign inflammatory condition, which can be successfully managed non-operatively [1,2,5]. The many causes of peripheral eosinophilia include inflammatory allergic diseases, parasitic infestations, collagen vascular diseases and haematological malignancies. As systemic diseases rarely present with manifestations in the breast [4], it remains a rare site for tissue eosinophilia to manifest. The few reported cases in literature have shown association with asthma, Churg-Strauss disease and hyper-eosinophilic syndrome [2–6] presenting as a unilateral breast disease. The present patient, however, presented with bilateral breast lumps with axillary lymphadenopathy on both sides. She had significant peripheral eosinophilia without any lower respiratory tract symptoms. Eosinophilic mastitis needs to be distinguished from carcinoma breast because of therapeutic implications. Eosinophilic mastitis though responds well to steroids, is known to recurs even after surgery indicating the importance of basic disease control and that of eosinophilia [1–5]. Komenalka et al. [4] described a case where a patient after undergoing surgery presented with a large mass after 2 years in the same breast. A clinical and/or radiologically suspi-

A. Singh et al. / Bilateral Eosinophilic Mastitis: An uncommon unheard entity

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Fig. 2. (a, b, c) Massive infiltration of eosinophilic granulocytes seen around the ducts and lobules filled with intraluminal secretory material at places[H and E X100]. (d, e, f) The involved ducts and lobules display focal reactive epithelial changes with enlarged nuclei and prominent nucleoli surrounded by eosinophils [H and E X400]. (Colours are visible in the online version of the article; http://dx.doi.org/10.3233/BD-140385)

cious breast lump in an asthmatic woman with peripheral eosinophilia should be diagnosed as Eosinophilic mastitis if malignancy is ruled out on cytological analysis thus avoiding an unnecessary surgery [1]. The only indication of surgery is to rule out malignancy in those patients not responding to medical therapy [4,5]. Peyman [7] described a case of bilateral mastitis, which occurred in the ante partum period. Most cases of mastitis need antibiotic therapy as they are usually associated with infective pathology mainly bacterial in nature but cases of eosinophilic mastitis respond to steroid treatment. Histopathologically, it is a rare type of mammary inflammation characterised by an extensive eosinophilic infiltrate around the mammary ducts and lobules. Lymphocytes and plasma cells are often admixed with the eosinophilic infiltrate. A granulomatous reaction may rarely be observed. As the involved ducts and lobules may display reactive epithelial changes seen as enlarged nuclei, high N/C ratio with prominent nucleoli, care should be taken not to mistake these for DCIS [9]. Few authors have opinion that eosinophilic mastitis is not associated with peripheral eosinophilia or an allergic condition. It just reflects a localised inflammatory reaction to intraluminal secretory material [4,9, 10]. The cases which are without features of secretory activity a carefully bacterioscopic and microbiologic

work-up of fresh material from the surgical specimens is necessary for a final diagnostic report. Eosinophilic mastitis is a great masquerade of malignancy both clinically and radiologically. Therefore histopathological examination is must in such cases due to rarity of lesion and unusual pathological features [4,5,10]. 4. Conclusion Pathologist, radiologist and surgeon must know regarding this rare condition as a positive diagnosis could potentially save the patient from mutilating radical surgery. It is important to distinguish from breast cancer because of the dramatic response to steroids of eosinophilic mastitis. Diagnosis is difficult due to the rarity and non specificity of the pathology. So in difficult cases diagnostic biopsy is necessary. Conflict of interest No conflicts of interest. References [1]

Garg M, Kumar S, Neogi S. Eosinophilic Mastitis masquerading as breast carcinoma. JSCR. 2012 6: 1.

36 [2] [3] [4]

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A. Singh et al. / Bilateral Eosinophilic Mastitis: An uncommon unheard entity Tavassoli FA. Pathology of the breast 2nd ed New York McGraw Hill, 1999. Topal NB, Topal U, Gokalp G, Saraydaroglu O. Eosinophilic mastitis. JBR-BTR 2007 May-Jun; 90(3): 170-1. Komenalka IK, Schnabel FR, Cohen JA, Saqi A, Mercado C, Horowitz E. Recurrent eosinophilic mastitis. Am Surg 2003 Jul; 69(7): 620-3. Villalba-Nuno V, Sabate JM, Gomez A, Vidaller A, Catala I, Escobedo A et al. Churg-Strauss syndrome involving the breast a rare cause of eosinophilic mastitis. Eur Radiol 2002 Mar; 12(3): 646-9.

[6]

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Thompson AB, Barron MM, Lapp NL. The hypereosinophilic syndrome presenting with eosinophilic mastitis. Arch Intern Med 1985 Mar; 145(3): 564-5. Peyman Alibeigi, Omid Reza Hosseini, Sepideh Assar Bilateral Antepartum Mastitis Iran J Med Sci 2010; 35(4): 327330. World Health Organization. Mastitis: causes and management. WHO/FCH/CAH/00.13. Geneva: WHO, 2000. Essentials of Diagnostic Breast Pathology: A Practical Approach, Farid Moinfar, Springer, 10-Aug-2007 page no 422. Bässler R. Mastitis. Classification, histopathology and clinical aspects. Pathologe 1997 Jan; 18(1): 27-36.

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Bilateral eosinophilic mastitis: an uncommon unheard entity.

We are reporting a case of bilateral eosinophilic mastitis which is rare and hardly heard. It is a mimicker of carcinoma breast both clinically & radi...
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