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|Year : 2013 | Volume
| Issue : 1 | Page : 94--95
Breast abscess: Sole manifestation of Salmonella typhi infection
A Banu1, MMN Hassan2, M Anand1,
1 Department of Microbiology, Bangalore Medical College and Research Institute, Bangalore, Karnataka, India
2 Department of General Surgery, Bangalore Medical College and Research Institute, Bangalore, Karnataka, India
Department of Microbiology, Bangalore Medical College and Research Institute, Bangalore, Karnataka
|How to cite this article:|
Banu A, Hassan M, Anand M. Breast abscess: Sole manifestation of Salmonella typhi infection.Indian J Med Microbiol 2013;31:94-95
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Banu A, Hassan M, Anand M. Breast abscess: Sole manifestation of Salmonella typhi infection. Indian J Med Microbiol [serial online] 2013 [cited 2019 Nov 17 ];31:94-95
Available from: http://www.ijmm.org/text.asp?2013/31/1/94/108753
Enteric fever is endemic in developing countries such as India where sanitary conditions and potable water is not accessible to all. Patients typically present at the end of the first week with fever, a dull frontal headache and malaise but with few physical signs. A tender abdomen, hepatomegaly, and splenomegaly are common as is relative bradycardia. If untreated or in case of resistance, there may be seeding of Salmonella in various organs of the body. Such patients usually present with abscess formation and fever.  Here we present a rare case of a middle aged, non lactating, immunocompetent female who presented with a breast abscess due to Salmonella typhi.
A 40-year-old female, who works as a Municipal worker involved in cleaning streets in Bangalore, presented to the surgical outpatient department (OPD) of our hospital with the complaints of pain and a swelling in the left breast since 10 days which was small to begin with and gradually progressed to the present size. The pain was severe, aching in nature and non-radiating. There was no history of associated discharge from the nipples. On deeper interrogation, the patient gave a history of diarrhoea for 2 days about 10 days before the appearance of the swelling for which she was treated with intravenous fluids. It was not associated with fever, headache or malaise. She did not take any antibiotics for the same. Her personal, past and family history were unremarkable. She is a mother of one male child delivered uneventfully 16 years ago. At the time of presentation, the patient was neither pregnant nor lactating. There was no history of prior vaccination against typhoid.
On examination, the patient was afebrile, her pulse rate was 76/min, regular, good volume. Other vitals were stable. There was no pallor, icterus or macules on the skin. The abdomen was soft, non tender with no organomegaly. Other general physical and systemic examination was unremarkable. On local examination, there was a firm lump in the upper, outer quadrant of the left breast measuring around 3 × 3 cm, non adherent to the skin, tender to touch with redness and warmth of the overlying skin. No dilated veins were appreciated and no axillary lymph nodes were palpable. Under local anaesthesia, 300 ml of pus was drained from the abscess and was sent to the department of Microbiology for culture and sensitivity. The patient was started on a combination of amoxicillin and Clavulanic acid 625 mg bid on out patient basis after surgical debridement and was asked to come for follow up. In the Microbiology laboratory, a Gram stained smear was made directly from the pus sample which showed the presence of plenty of inflammatory cells along with Gram negative bacilli. According to the routine procedure, the pus was plated onto McConkey agar and chocolate agar and incubated at 37C. After 18 hours of incubation, the McConkey agar showed presence of non lactose fermenting colonies. Biochemical reactions were put up for further identification and antimicrobial susceptibility plates were put up on Mueller Hinton agar. The organism was negative for indole production, citrate utilization and urease production. Mannitol motility test medium showed that the organism fermented mannitol and was motile. Triple sugar iron agar gave a reaction of alkaline slant/acid butt with a streak of H 2 S at the point of inoculation. A presumptive diagnosis of Salmonella typhi was made and was confirmed by agglutination test with specific antisera. The isolate was sensitive to ampicillin, chloramphenicol, cefotaxime, nalidixic acid, ciprofloxacin and co-trimoxazole.
Based on these findings, when the patient was recalled to the hospital, after 4 days, there was no healing of the abscess clinically.
Urine and stool samples were collected and processed in the laboratory for culture and sensitivity. The urine showed no growth while the stool showed presence of normal commensals. A serum sample was also collected and subjected to Widal test which showed a titre of TO = 80 and TH = 320. Her hemogram revealed normal values and biochemistry investigations were also within normal limits. She was HIV and HBsAg negative. The patient was started on oral ciprofloxacin 500 mg bid for 2 weeks along with surgical debridement on alternate days to which she responded favourably and the abscess healed with no further complications. She was discharged with advice to follow up. At the subsequent follow up after 1 month, there was complete healing of the abscess.
Informed, written consent was taken from the patient to publish this case in medical literature.
Bacteraemia is a constant feature of enteric fever, which is usually caused by S.typhi, and its dissemination may lead to localized foci of infection forming abscesses in various organs such as liver, subcutaneous tissue, muscles, and skin.  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%.  On analysis of the available literature on breast abscesses due to Salmonella spp., it was found that most of the patients were immunocompetent females between the ages of 23 and 45 years and were nonlactating. However, no common predisposing factors could be elucidated. 
There has been a significant variation in the prevalence of breast abscess due to S. typhi infection in the available literature from less than 10 cases to 30 cases. This however, indicated the rarity of breast abscess as a consequence of Salmonella infection. 
Madelung and Erbosloh suggested that the isolation of the pure Salmonella typhi from breast abscess was impossible.  But in present case and in a few other cases reported by Singh et al.,  Jayakumar et al.,  Singh et al.,  Vishwanathan et al.  isolation of Salmonella typhi from breast abscess material was possible.
In present case, besides diarrhoea there was no preceding typical manifestation of typhoid. Since the patient was not subjected to diagnostic procedures and was symptomatically treated for the diarrhoeal episode there is a possibility that she might have had transient bacteremia due to Salmonella which was not detected. This could have led to the seeding of organism in the breast tissue. There was also no pre existing or underlying breast disease or predisposing conditions like pregnancy or lactation which makes this case unique. The pure isolation of Salmonella typhi in culture from the breast aspirate along with significant Widal titres were the only factors in favour of diagnosis.
Kumar  reported a multidrug resistant typhoid with breast abscess. In present case however the isolate of Salmonella typhi showed good susceptibility to all drugs tested.
This patient was initially treated with amoxicillin clavulanic acid because the most common organism causing breast abscess is Staphylococcus aureus. Hence, this case is a reminder to the clinicians, that breast abscess can also be caused by Salmonella typhi which is very rare. Microbiological evaluation of a properly obtained specimen is mandatory in such unusual pyogenic infections.
To conclude any breast abscess in a nonlactating female even without a history of typhoid fever in the recent past and no other predisposing factors must be evaluated, keeping the possibility of a Salmonella breast abscess in mind and the pus aspirated must be sent to the Microbiology laboratory for culture and sensitivity. If not done, such a diagnosis could be easily missed.
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