Mammary abscess in undiagnosed, newly onset diabetes mellitus type 1—a case report

Introduction

The following unique case report demonstrates how non-puerperal breast abscess (NPMA) was the initial manifestation in an undiagnosed diabetes mellitus 1 (DM1) patient while underlining the importance of considering undiagnosed DM1 as a possible cause for a breast abscess. Breast abscesses as an initial presentation of DM1 are not frequently reported in the current medical literature when exploring this realm, suggesting that this association may be relatively uncommon.

This case contributes to the medical literature by increasing our understanding of the diverse presentations and associations of DM1, aiding in early diagnosis, and optimizing management strategies for patients with similar clinical scenarios.

NPMA is a condition characterized by localized accumulation of pus within the breast tissue, unrelated to breastfeeding. In contrast, to a lactational breast abscess that occur in breastfeeding women, NPMA can affect women of all ages and reproductive states. The most common cause of infection is due to obstruction of milk ducts leading to a breading ground for bacteria to strive in, and skin fissures over the mammary glands enabling bacteria to form abscesses. Other risk factors include breast surgery, compromised immune system increasing susceptibility to infections, underlying malignancy, smoking, and notably, diabetes mellitus, which can impair the immune system due to hyperglycemia which inhibits among other processes both neutrophil migration and phagocytosis leading to infection and abscess (1,2).

Abscesses occur more frequently in patients with DM1 (3). Although abscesses typically occur in patients already diagnosed with DM1, they can also be the first symptom and initial presentation of DM1 (4). We present this case in accordance with the CARE reporting checklist (available at https://asj.amegroups.com/article/view/10.21037/asj-24-12/rc).

Case presentation

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

A 24-year-old female with a body mass index (BMI) of 23.8 kg/m², non-smoker, otherwise healthy apart from schizotypal personality disorder, for which she did not take any medication for and did not have any other medication history was referred by her general practitioner to the Department of Plastic and Breast Surgery due to complaints of pain and redness of her left breast. During the consultation, the patient did not show any explicit signs of her psychiatric disorder and responded relevantly to all questions asked. Given no suspicion of pregnancy or inflammatory breast cancer, NPMA was primarily suspected, which has a prognosis of 2–3 weeks for full recovery given the correct treatment is administered (2). The objective examination revealed periareolar redness, swelling, and a 2×4 cm area of fluctuation. Apart from this, the consultation was unremarkable. The patient had no prior history of mammary abscesses. Supporting NPMA as a preclinical symptom for DM1 can be traced to several factors, including immune dysfunction and delayed wound healing. DM1 can manifest with atypical symptoms, particularly in the preclinical stage when blood glucose levels may not yet be significantly elevated. The suspicion of NPMA was reinforced, since the patient had absence of other typical diabetes symptoms.

An ultrasound (US) examination of the left breast conducted the same day revealed a 39×25×28 mm abscess cavity (Figure 1) confirming the suspicion of NPMA. Under US guidance, 20 mL of pus was aspirated using a needle for culture and susceptibility testing (C + S).

Figure 1 Ultrasound examination confirming mammary abscess at initial consultation.

The patient was initiated on appropriate antibiotics, namely 1 g dicloxacillin tablets four times daily for 10 days, and scheduled for follow-up 1 week later with instructions to seek prompt care if worsening occurred.

Between the initial consultation and the 1-week follow-up, the patient experienced nausea and vomiting, leading to self-discontinuation of antibiotics. After a phone consultation the symptoms were interpreted as a side effect of dicloxacillin. After receiving the C + S results, indicating strong growth of S. Aureus, the antibiotic treatment was changed to clindamycin tablets 300 mg three times daily.

At the 1-week follow-up, an US was conducted displaying significant regression of the abscess cavity (Figure 2). Clinical improvement regarding NPMA was seen, but the patient complained of fatigue and persistent nausea. This was attributed to the newly initiated antibiotic treatment, and a 2-week follow-up was planned with continued antibiotic therapy.

Figure 2 One week after debut of mammary abscess, ultrasound examination confirming regression.

Two days after the 1-week control follow-up, the patient was seen due to worsening of her nausea and vomiting. The physician observed no acute general deterioration except for ongoing nausea and increasing vomiting. Vital signs were normal, a systematic objective examination was conducted, and clinical symptoms of NPMA were diminishing, leading to discontinuation of antibiotic treatment due to it being the suspected cause for the nausea and vomiting. The patient was thoroughly briefed and conservative management with advice on ample food and drink intake.

Approximately 12 hours later, the patient was admitted due to cerebral confusion, persistent nausea, and increasing frequency of vomiting. In the emergency department blood gas sample revealed hyperglycemia (77 mmol/L, reference range, 2.9–8.3 mmol/L), ketonuria, and low pH value (7.09, reference range, 7.35–7.45), indicative of fulminant diabetic ketoacidosis. The patient was transferred to the intensive care unit, and her dehydrated and metabolic state was treated. She recovered without sequelae.

Endocrinological assessment with positive GAD65 coupled with the patients insulin-requiring status confirmed the diagnosis of DM1. The patient was seen 2 weeks after discharge from the intensive care unit for a follow-up consultation in the Department of Plastic and Breast Surgery, with full remission of NPMA and a third US follow-up one week later showing nearly complete regression of the cavity (Figure 3), obviating the need for further treatment. The individual events of this case report can be viewed organized as a timeline in Figure 4.

Figure 3 Complete regression of the mammary abscess 3 weeks after initial consultation.

Figure 4 Timeline of the individual events in the case report.

Discussion

This case report describes a rare and atypical presentation of NPMA in the context of undiagnosed, onset DM1. Some studies (1,3,4) have suggested a potential association between NPMA and DM1, highlighting the importance of understanding this relationship for early diagnosis and management. The causality between NPMA and DM1 can potentially be explained by impairment of the immune system. This immunocompromised state can predispose patients to infections, including those affecting breast tissue, such as NPMA. Increase in blood glucose levels in DM1 has the potential to create a favorable environment for bacterial growth and proliferation. This increased glucose availability can enhance bacterial colonization within the breast tissue, contributing to development of abscesses. Vascular degeneration which is seen in DM1 (5) in the form of microangiopathy can additionally compromise blood flow, which in turn counteracts the body’s ability to combat infections and facilitating abscess formation. As a result of this case, we urge clinicians to screen patients presenting with NPMA for hyperglycemia. Early recognition and treatment of infections in the breast in individuals with DM1 are imperative to prevent the progression to abscess formation. This can include early initiation of broad-spectrum antibiotics, along with close monitoring for signs of treatment response or failure. Educating patients with DM1 about the importance of regular breast self-examinations, early recognition of signs of infection, and adherence to diabetic management can empower them to participate actively in their care and promote early diagnosis and treatment of NPMA.

Conclusions

The development of NPMA due to undiagnosed and early onset of DM1 is possible to occur. The possible association between NPMA and DM1 underlines the importance of a comprehensive approach to diagnosis and management including screening for DM1. By understanding the causality between these two conditions and implementing strategies for early diagnosis, glycemic control, and aggressive management of infections, clinicians can improve outcomes and reduce complications in patients affected by NPMA and diabetes mellitus.

Acknowledgments

Funding: None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://asj.amegroups.com/article/view/10.21037/asj-24-12/rc

Peer Review File: Available at https://asj.amegroups.com/article/view/10.21037/asj-24-12/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://asj.amegroups.com/article/view/10.21037/asj-24-12/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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