|Year : 2015 | Volume
| Issue : 1 | Page : 33-35
Infected epidermoid cyst masquerading as breast abscess in a male
M Midya, NK Dewanda
Department of General Surgery, Government Medical College and Associated Group of Hospitals, Kota, Rajasthan, India
|Date of Web Publication||13-Mar-2015|
N K Dewanda
Department of General Surgery, Government Medical College and Associated Group of Hospitals, Kota - 324 001, Rajasthan
Source of Support: None, Conflict of Interest: None
Male breast abscess is a rare occurrence. Few cases have been reported earlier in association with human immunodeficiency virus infection, salmonella infection, and breast cancer. However, male breast abscess resulting as a complication of epidermoid cyst has not been reported yet. The diagnosis of male breast abscess is clinical. The typical inflammatory skin changes can be noteworthy clue to the diagnosis. Ultrasonography and fine needle aspiration cytology are useful adjuncts in making diagnosis and finding the probable etiology of the abscess. The treatment of simple male breast abscess is incision and drainage along with daily dressings. In the presence of infected epidermoid cyst as the underlying pathology, the cyst wall should be completely excised to prevent recurrence. We describe an interesting case of male breast abscess occurring due to infected epidemoid cyst which was treated adequately with incision and drainage along with cyst wall excision and post-operative regular wound dressings.
Keywords: Epidermal inclusion cyst, fine-needle aspiration cytology, incision and drainage, infected epidermoid cyst, male breast abscess
|How to cite this article:|
Midya M, Dewanda N K. Infected epidermoid cyst masquerading as breast abscess in a male
. Arch Int Surg 2015;5:33-5
| Introduction|| |
Male breast abscess (MBA) is a rare occurence.  It may be associated with human immunodeficiency virus infection,  Salmonella More Details infection,  and breast cancer.  Epidermoid cyst (EC) also known as Epidermal inclusion cyst (EIC) , of the male breast is also an infrequent entity. Kapila and Verma  reported only five cases of EIC on fine needle aspiration cytology (FNAC) out of 424 benign aspirates from 651 males over a period of 22 years of which only 2 were detected as infected EIC. We report a case of infected EC presenting as MBA. To the best of our knowledge, we are yet to come across a clinical case of infected EC causing breast abscess in males.
| Case Report|| |
A 60-year-old male presented with a painful lump in the right breast of 4-days duration. [Figure 1] It was sudden in onset, rapidly progressing and associated with fever for last 2 days. He had a small painless swelling at the same site for the last 2 years which was slowly progressive in nature. There was no history of diabetes mellitus, tuberculosis, trauma, previous surgery at the same site, or treatment for any other chronic illness. There was no history of breast cancer in the family.
|Figure 1: Pre-operative image of the male patient showing a lump in the right breast with the skin over the lump inflamed. The left breast is normal|
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General physical examination was normal. Local examination revealed a 5 × 5 cm tender lump on the right breast under the nipple areola complex fixed to the overlying skin but mobile on the underlying structures. The skin over the lump was inflamed. Nipple discharge was absent and axillary lymph nodes were not palpable.
Routine hematological and serum biochemistry were essentially normal but for the leukocytosis (white blood cell count of 14400/ mm 3 ) with predominance of neutrophils (78%) on differentials.
A clinical diagnosis of MBA was made and incision and drainage (I & D) of the abscess was planned. A preliminary wide bore needle aspiration of the abscess showed pus with cheesy material. This alerted us to the possibility of some other coexisting pathology. Formal FNAC was done which showed anucleated squames on the background of abundant neutrophils suggestive of a probable diagnosis of infected EC [Figure 2].
|Figure 2: Fine needle aspiration cytology (FNAC) (Giemsa stained, 400×) from the lesion showing anucleated squames on the background of abundant neutrophils suggestive of a probable diagnosis of infected EC|
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The patient was treated with drainage of abscess and excision of residual cyst wall of the EC under local anaesthesia [Figure 3]. Histopathological examination of the excised cyst wall specimen showed keratinized stratified squamous epithelium producing laminated keratin suggestive of EC [Figure 4]. The patient recovered well on daily dressings and oral antibiotics.
|Figure 3: Intra-operative photograph after I & D showing residual cyst wall which was excised and sent for histopathological examination|
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|Figure 4: Histopathological photomicrograph (Hematoxylin & Eosin stained, 400×) from cyst wall biopsy showing keratinised stratified squamous epithelium producing laminated keratin|
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| Discussion|| |
EC is a kind of adnexal tumor of pilosebaceous origin.  EC have been referred to by various terms including EIC, epidermal cysts, or follicular infundibular cysts. However, the term EIC refers specifically to a EC that is the result of the implantation of the epidermal elements in the dermis.  Grossly, they often present as outward protrusions of the skin. However, in the breast they are frequently inclusion cysts expanding in toward the flexible subcutaneous tissue. The cysts are filled with lamellated keratin. 
EIC can be congenital or acquired.  The acquired cases can occur after trauma, reduction mammoplasty, breast augmentation, needle biopsy, and squamous metaplasia of the columnar epithelium of the ducts. 
Various complications can occur with EIC of the breast like the spontaneous rupture and development of cancer.  Complicated EC may present as swelling or abscess. Whang et al. states that in spontaneous rupture these cysts release non-absorbable keratin that acts as an irritant leading to secondary foreign body type reactions, granulomatous reaction or abscess formation.  The diagnosis of male breast abscess is usually clinical. The typical inflammatory skin changes can be noteworthy clue to the diagnosis. Ultrasonography (USG) of the breast can be helpful in the diagnosis of subareolar abscess.  USG may show a heterogeneous irregular hypoechoic mass with increased vascularity in the surrounding tissue on colour Doppler flow in the periphery of the lesion.  However, USG findings can occasionally mimick a carcinoma. , FNAC plays an important role in the preoperative diagnosis of infected EIC because of its typical pultaceous aspirate and cytomorphological features comprising of anucleated squames in the background of neutrophils. 
The treatment of simple MBA is incision and drainage with daily dressings. However, in the presence of infected EC as the underlying pathology, the cyst wall should be completely excised to prevent recurrence.  Histopathological examination of the excised cyst wall is necessary to confirm the diagnosis of EC and rule out the potential complication of malignancy. The above case is extraordinary because of the unusual finding of MBA resulting as a complication of EC, probably idiopathic in etiology, occurring in a patient without any history of trauma, carcinoma, or any previous surgical intervention at the same site.
| Conclusion|| |
Breast abscess in males can be due to a myriad of etiological possibilities such as cancer or as a complication of infected epidermoid cyst. We should be vigilant to detect other underlying pathology which needs specific management and treatment.
The treatment of simple male breast abscess is incision and drainage along with daily dressings. In the presence of infected epidermoid cyst as the underlying pathology, the cyst wall should be completely excised to prevent recurrence.
| Acknowledgement|| |
We sincerely thank Dr. R. K Aseri, Principal and Controller and Dr. R. S Meena, Senior Professor and Head, Department of General Surgery, Government Medical College and associated group of hospitals, Kota (Rajasthan) for their constant support and encouragement in writing this research paper and other such research activities currently going on in our department.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]