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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 4  |  Issue : 1  |  Page : 7-9

Necrotizing fasciitis of the breast in Ahmadu Bello University Teaching Hospital, Zaria, Northwestern Nigeria


1 Department of Surgery, ABUTH, Zaria, Nigeria
2 Department of Surgery, University of Benin Teaching Hospital, Benin City, Edo State, Nigeria

Date of Web Publication15-Oct-2019

Correspondence Address:
Dr. Peter Pase Abur
Department of Surgery, ABUTH, Zaria
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/archms.archms_4_19

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  Abstract 


Context: Necrotizing fasciitis of the breast is rare globally. There is an observed increase in the number of cases seen in our hospital. Moreover, there is no previous documentation on the disease from this center. Aims: The aim was to highlight the clinical features, predisposing factors, complications, treatment, and outcome of necrotizing fasciitis of the breast. Settings and Design: It was a 5-year prospective study from January 2012 to December 2016. Subjects and Methods: The biodata, clinical features, predisposing factors, complications, treatment, and outcome of necrotizing fasciitis of the breast were documented. Statistical Analysis Used: The results were analyzed using SPSS software version 21 and presented as percentages and charts. Results: Thirty-nine out of 163 women with infective breast disease had necrotizing fasciitis of the breast. Majority of the patients (28 [71.8%]) were <31 years. Most of the patients had low educational status (33 [84.6%]). The most common clinical features were foul-smelling discharging ulcers/sinuses and necrosis of the skin of the breast in all patients. Majority of the patients (29 [74.4%]) were lactating mothers. Poorly treated mastitis/breast abscess was the predominant predisposing factor. Culture revealed polymicrobial organisms in 20 (51.3%) patients. Thirty-six (92.3%) patients had serial wound debridement, 25 (64.1%) had split-thickness skin grafting, and 3 (7.7%) had toileting mastectomy. Mortality rate was 10.3%. Conclusions: Necrotizing fasciitis of the breast is not uncommon in our center. Majority of the patients were illiterate with low socioeconomic status. Poorly treated mastitis/breast abscess in lactating women was the major predisposing factor.

Keywords: Breast, necrotizing fasciitis, Nigeria, northwestern


How to cite this article:
Abur PP, Yusufu LM, Odigie VI. Necrotizing fasciitis of the breast in Ahmadu Bello University Teaching Hospital, Zaria, Northwestern Nigeria. Arch Med Surg 2019;4:7-9

How to cite this URL:
Abur PP, Yusufu LM, Odigie VI. Necrotizing fasciitis of the breast in Ahmadu Bello University Teaching Hospital, Zaria, Northwestern Nigeria. Arch Med Surg [serial online] 2019 [cited 2019 Nov 13];4:7-9. Available from: http://www.archms.org/text.asp?2019/4/1/7/269235




  Introduction Top


Necrotizing fasciitis (NF) of the breast is a severe progressive infective gangrene of the subcutaneous tissue of the breast with subsequent death of the overlying skin.[1] It is a life-threatening condition associated with high morbidity and mortality rate. Predisposing factors include poorly treated mastitis or abscess in pregnant or lactating mothers, trauma, bites, foreign body, surgical wound sites, intravenous drug abusers, diabetes mellitus, and immunocompromised host or can be idiopathic. NF of the breast is extremely rare. To date, just few case reports detailing NF of the breast exist in literature.[1] However, there has been an observed increase in the number of cases seen in our hospital. Despite this, there is no documentation on NF of the breast in this center.

The aim of this study was to document the clinical features, predisposing factors, complications, treatment, and outcome of NF of the breast.


  Subjects and Methods Top


This was a prospective study from January 2012 to December 2016.

The biodata, clinical features, predisposing factors, complications, treatment, and outcome of NF of the breast were documented. Patients gave informed consent, and ethical clearance was obtained.

The results were analyzed using SPSS software version 21, 2012 (IBM, Armonk, New York, USA) and presented as percentages and simple charts.


  Results Top


Thirty-nine of 163 women with infective breast disease had NF of the breast in the study period. Age ranged between 16 and 50 years old. [Table 1] shows the age distribution. Nineteen (48.7%) patients had Quranic education, 14 (35.9%) had primary education, and 6 (15.4%) had secondary education. Sixteen (41.0%) patients had an estimated monthly income of couple of less than ten thousand naira (<28 dollars), 12 (30.8%) patients had between 10,000–20,000 Naira, and 4 (10.2%) patients had more than 30,000 Naira. The main clinical features were foul-smelling discharging ulcers/sinuses in 39 (100%) patients and necrosis of the skin in 39 (100%) patients. [Table 2] shows clinical features. Fourteen (35.9%) patients presented within 14–20 days of onset of symptoms to hospital, 10 (25.6%) within 7–13 days, 8 (20.5%) within 1–6 days, and 7 (18.0%) after 21 days. Thirty-four (87.27%) of the patients received nonorthodox/traditional treatment before presentation to our hospital, whereas 5 (12.8%) received orthodox treatment. The major predisposing factors were poorly treated mastitis and breast abscess in 34 (87.2%) patients and lactation in 29 (74.4%) patients. [Table 3] shows predisposing factors. The complications were extensive skin loss in 35 (89.7%) patients, milk fistula in 17 (43.6%), septicemia or septic shock in 15 (38.5%), 4 (10.2%) had unilateral nipple loss, 1 (2.6%) had bilateral nipple loss, and 4 (10.3%) had multiple-organ failure. The treatments received were wound debridement in 36 (92.3%), antibiotics in 39 (100%), split skin grafting in 25 (64.1%), mastectomy in 3 (7.7%), and 28 (71.8%) had blood transfusion. Twenty-four (61.5%) patients stayed in the hospital for more than 6 weeks, 8 (20.5%) between 3 and 6 weeks, and 7 (18.7%) <3 weeks. For the outcome, 20 (51.3%) patients had split skin graft and were happy with the outcome. Five patients (12.8%) had nipple loss and were worried of inability to breastfeed in subsequent pregnancies, 3 (7.7%) had mastectomy and were worried for losing breast for nonmalignant condition, and 7 (18%) absconded and did not present for skin grafting.
Table 1: Age distribution of necrotizing fasciitis of the breast

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Table 2: Clinical features

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Table 3: Predisposing factors

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  Discussion Top


NF is a rare but aggressive soft-tissue infection commonly affecting the abdominal wall, perineum, and extremities. Although it can occur at any site on the body, NF of the breast is a rare entity, with very few cases reported in the literature.[1] It was first described in the literature by Shah et al. in 2001, and only a handful of cases have since been published.[2] However, it is common in our center constituting 23.9% of all infective breast disease. This may be explained by the low socioeconomic status of the patients, low educational level, and preference for traditional treatment over orthodox for breast diseases. Majority of the reported cases were primary NF of the breast with no previous trauma or intervention and mostly in nonlactating woman.[2],[3],[4],[5] In this study, majority of cases (34 [87.2%]) was secondary NF following poorly treated mastitis or breast abscess in pregnant or lactating mothers. Instead of seeking for help in a hospital, the patients resulted in seeking assistance in traditional treatment, where incisions were made and local concoctions applied to the breast. This resulted in NF of the breast.

Based on causative organism, NF is divided into two types – Type I polymicrobial infections including anaerobes and Type II which is caused by Group A streptococcal organisms with or without staphylococci.[6] In this study, majority of the cases (87.3%) were polymicrobial with Klebsiella, Pseudomonas, Proteus, and Streptococcus organisms isolated. This is similar to the culture of case report of NF of the breast by Soliman et al.[7] There was no facility to culture anaerobes in our center, and in six cases, there was no isolated organism. Diagnosis of NF is mainly based on the clinical ground (severe pain disproportionate to local finding along with systemic toxicity), but adjuvant such as laboratory risk indicator for NF scoring system can lead to precision in diagnosis.[8] Early diagnosis is not always possible because signs such as erythema, tenderness, swelling, and fever accompany other inflammatory state of the skin and subcutaneous tissue. Large hemorrhagic bullae, skin necrosis, sensory deficits, and crepitus are all late features.[6],[9] In this study, all the patients presented late with skin necrosis, sensory loss, and foul-smelling discharging sinuses/ulcers. This is due to illiteracy and low socioeconomic status. The patients were often neglected and present late after failed treatments from local remedies. This is similar to other developing countries such as India.[10] The most common complication was extensive skin loss. This was as a result of late presentation to the hospital and the effect of the local concoction that usually causes skin necrosis following application. In two patients, the traditional doctor applied the concoction on the normal breast for prophylactic treatment causing bilateral NF of the breast. A significant number of the patients developed milk fistula because they were lactating, but this was treated by suppressing lactation with bromocriptine and subsequent split-thickness skin grafting.

The most important issue in the management of NF in general and in the breast is the immediate surgery with extensive debridement of all nonviable tissue, intravenous antibiotics; therapy guided by culture and sensitivity result and repeated unlimited number of debridement until no more necrotic tissue is seen.[11] In this study, our patients had serial wound debridement, intravenous ceftriaxone, and metronidazole initially, but this was subject to change based on the patient's response or culture and sensitivity results. Intravenous fluid and blood transfusion were given when indicated. Twenty-five patients (64.1%) subsequently had split-thickness skin grafting. However, three patients had toilet mastectomy for extensive necrosis of the breast and the other two patients had associated breast cancer.

In literature, some case reports of NF of the breast were managed by mastectomies;[2],[3],[4] some managed conservatively without resorting to mastectomy.[5],[11] In our environment, patients insist on conservative management even when the nipple is destroyed completely; this may be because of fear of mastectomy, low educational level, poverty, and inability to represent for reconstructive surgery. For the outcome, 51.3% of patients had split-thickness skin graft and were happy with the outcome. Those that had nipple loss were worried of inability to breastfeed in subsequent pregnancies, while the patient who had mastectomy was worried for losing her breast for a nonmalignant condition. Despite proper counseling, a significant number (18%) of our patients absconded and did not present for skin grafting. This may be as a result of poverty and low educational level.


  Conclusions Top


NF of the breast is not uncommon in our center. Majority of the patients were in their reproductive age and were illiterate and of low socioeconomic status. Poorly treated mastitis/breast abscess in pregnant or lactating mothers was the major predisposing factor. Serial wound debridement and subsequent skin grafting were the major treatment options. Mastectomy was done in 7.7% of patients. Mortality rate was 10.3%. Improving girl child education in Northwestern Nigeria will improve the socioeconomic status and reduce the high dependency level on traditional treatment, thereby reducing the incidence and morbidity of NF of the breast. There is a need to teach mothers how to take adequate care of lactating breast and good hygiene and present early to hospital.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Fayman K, Wang K, Curran R. A case report of primary necrotising fasciitis of the breast: A rare but deadly entity requiring rapid surgical management. Int J Surg Case Rep 2017;31:221-4.  Back to cited text no. 1
    
2.
Shah J, Sharma AK, O'Donoghue JM, Mearn B, Johri A, Thomas V. Necrotizing fasciitis. Br J Plast Surg 2001;54:67-79.  Back to cited text no. 2
    
3.
Rajakannu M, Kate V, Ananthakrishnan N. Necrotizing infection of the breast mimicking carcinoma. Breast J 2006;12:266-7.  Back to cited text no. 3
    
4.
Nizami S, Mohiuddin K, Mohsin-e-Azam, Zafar H, Memon MA. Necrotizing fasciitis of the breast. Breast J 2006;12:168-9.  Back to cited text no. 4
    
5.
Wong CH, Tan BK. Necrotizing fasciitis of the breast. Plast Reconstr Surg 2008;122:151e-2e.  Back to cited text no. 5
    
6.
Elliott DC, Kufera JA, Myers RA. Necrotizing soft tissue infections. Risk factors for mortality and strategies for management. Ann Surg 1996;224:672-83.  Back to cited text no. 6
    
7.
Soliman MO, Ayyash EH, Aldahham A, Asfar S. Necrotizing fasciitis of the breast: A case managed without mastectomy. Med Princ Pract 2011;20:567-9.  Back to cited text no. 7
    
8.
Sarani B, Strans M, Pascal J, Schwab CW. Necrotizing fasciitis: Current concept and review of the literature. J Am Coll Surg 2009;208:229-88.  Back to cited text no. 8
    
9.
Taviloglu K, Yanar H. Necrotizing fasciitis: Strategies for diagnosis and management. World J Emerg Surg 2007;2:19.  Back to cited text no. 9
    
10.
Maroti PP, Vidyadhar PK, Laxmikant B, Akshay P. Necrotizing fasciitis of the breast: A rare presentation in post-partum mother. IOSR J Dent Med Sci 2013;11:16-8.  Back to cited text no. 10
    
11.
Shimizu T, Tokuda Y. Necrotizing fasciitis. Intern Med 2010;49:1051-7.  Back to cited text no. 11
    



 
 
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  [Table 1], [Table 2], [Table 3]



 

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Introduction
Subjects and Methods
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