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A Rare and Treatable Cause of Breast Lump: Sarcoidosis FREE TO VIEW

Gopi Khilnani, MD; Neetu Jain, MD; Arvind Kumar, MBBS; Ashu Bhalla, MD
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Department of Pulmonary Medicine and Sleep Disorders, All India Institute of Medical Sciences, New Delhi, India

Chest. 2014;146(4_MeetingAbstracts):425A. doi:10.1378/chest.1994291
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SESSION TITLE: Miscellaneous Global Case Reports

SESSION TYPE: Global Case Report

PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM

INTRODUCTION: Sarcoidosis is granulomatous disease which can involve any organ. Primary involvement of breast is rare and occurs in less than 1% cases of sarcoidosis.[1] It may masquerade malignancy which is a common cause of breast lump requiring urgent treatment.

CASE PRESENTATION: A 21-year-old female presented with complaints of intermittent fever for 3 months. She had no cough, expectoration, hemoptysis or breathlessness. There was no history of loss of weight or appetite. She noticed a lump in upper quadrant of left breast. On examination, she was febrile. There were no palpable cervical or supraclavicular lymph nodes, however, lymph node mass was palpable in left axilla. On breast examination, a hard and freely mobile mass, about 5 cms in diameter was palpable in upper quadrant of left breast. Systemic examination was unremarkable. Investigations revealed a normal hemogram. The erythrocyte sedimentation rate was 50 mm during 1st hour (Westergen). Blood sugars, renal and liver functions were normal and Mantoux test with 5 TU was negative. Chest radiograph showed widening of mediastinum with prominent left hilum. CECT chest revealed a large breast lump with enlarged homogenous mediastinal lymph nodes. The lung parenchyma was normal. Sputum for acid fast bacilli was negative on three occasions and ELISA for HIV was negative. FNAC from the breast under ultrasound guidance showed benign ductal epithelial cells, occasional giant cells and epithelioid cell granulomas without necrosis. The stain for acid-fast bacilli was negative. The patient had already received 2 months category I anti-tubercular drugs from elsewhere without improvement in symptoms. We considered sarcoidosis as an alternative diagnosis. Serum Angiotensin- converting enzyme (ACE) levels were 37u/L (normal: 20-40 u/L). Her serum Ca was 9.2 mg% and 24 hours urinary Ca was 0.11 gms/ 24 hrs. With a diagnosis of sarcoidosis she was started on oral prednisolone (30 mg/day). At the end of 3 months the patient showed significant clinical improvement and the mass was not palpable, following which corticosteroids were gradually tapered off.

DISCUSSION: Breast lump always acuse anxiety as carcinoma breast is a common cause. Presentation of sarcoidosis as breast lump is extremely rare. It is classically presents in women in third or fourth decade of life and frequently mimic breast malignancy.[1] It may be a sole manifestation which is known as “primary Mamary sarcoidosis” or may be a part of more wide spread systemic disease.[2] Patient may present as lump in breast, as was the case with our patient or may be found to have a mass on mammography. The mammographic or ultrasonographic finding may be like a malignancy, typically a spiculated or rounded mass or an area of architectural distortion. These masses may multiple or single and unilateral or bilateral.[2] Differential diagnoses may be carcinoma, ganulomatous mastitis, tuberculosis or fungal infections. It may be difficult to differentiate from tuberculosis in the endemic areas. A biopsy or ultrasound guided biopsy is required for diagnosis. Histopathology is non-caseating granulomas surrounded by benign ductal epithelial cells. Treatment primarily consists of systemic corticosteroids. The patients with only breast involvement not responding to corticosteroid may undergo surgical exicision.[3]

CONCLUSIONS: Although rare, sarcoidosis should be considered in the differential diagnosis of breast lumps.

Reference #1: Sabate JM, Clotet M, Gomez A, De Las Heras P, Torrubia S, Salinas T. Radiologic evaluation of uncommon inflammatory and reactive breast disorders. Radiographics. 2005; 25:411-24.

Reference #2: Nicholson BT, Mills SE. Sarcoidosis of the breast: An unusual presentation of a systemic disease. Breast J. 2007; 13:99-100.

Reference #3: Panzacchi R, Gallo C, Fois F, Dalpiaz G, Cucchi MC, Degli Esposti R, et al. Primary sarcoidosis of the breast: case description and review of the literature. Pathologica. 2010; 102:104-7.

DISCLOSURE: The following authors have nothing to disclose: Gopi Khilnani, Neetu Jain, Arvind Kumar, Ashu Bhalla

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