Fungal Infection of the Breast: Two Reported Cases Diagnosed by Fine Needle Aspiration (fna) Cytology

Objective To report two cases of fungal infection, zygomycosis and aspergillosis, of the breast, diagnosed by fi ne needle aspiration (FNA) cytology. In most reports, these fungal species are not frequently encountered in immunocompetent hosts. Both of our patients were in healthy condition. Materials and methods All breast FNA cases obtained over a 5 year period in Maharaj Nakorn Chiang Mai Hospital were reviewed. Only two cases of fungal infections were found. The FNA and histologic slides were reviewed. Results Case 1: A 42-year-old healthy woman presented with a 1.5 cm ill-defi ned mass at the left breast. FNA showed fungal hyphae, morphologically consistent with zygomycosis. The histologic study of a subsequent biopsy revealed fungal hyphae with broad and irregular branching, identifi ed by Gomori methenamine silver and Periodic Acid Schiff stains. Case 2: A 59-year-old woman with a history of intraductal carcinoma and treated with post-lumpectomy and chemotherapy, seven years before, presented with newly developed mass at the right breast. The cytology revealed multiple septate hyphae with dichotomous branching; a feature of aspergillus. The patient was treated by wide excision. Histologic examination showed abscesses containing septate hyphae. Conclusion Fungal infection of the breast is uncommon even in patients with immunocompromised status. Both of our patients were healthy, though one was previously diagnosed as having breast cancer and treated seven years before. Our study also emphasized the usefulness of FNA study in diagnosing fungal infection of the breast. Chiang Mai Medical Journal 2009;48(2):65-70. Keyword: breast, fungal infection, zygomycosis, aspergillosis, cytology, fi ne needle aspiration, histology 66 Sukhamwang N, Chaiwun B, Trakultivakorn H. Mycotic infections of the breast are uncommon, however, mammary aspergillosis has been reported at the site of prosthetic augmentation implants.(1) An invasive aspergilloma of the breast has also been reported in a patient with acute myeloid leukemia.(2) Mucormycosis is unusual in surgical practice, and these fungi usually affect patients who are severely immunocompromised.(3) One case of isolated breast mucormycosis was reported.(4) Our report presents a fi nding of aspergillus in a patient after a lumpectomy and chemotherapy, and a case of zygomycosis in a healthy woman. Case report Case 1 A healthy 42-year-old Thai woman presented with a history of palpable mass at the left breast. She did not complain of any tenderness or nipple discharge. Physical examination revealed an ill-defi ned mass of 1.5 cm located in the upper outer area of the left breast. There was no palpable axillary lymph node. Fine needle aspiration cytology showed numerous fungal hyphae, which were morphologically consistent with zygomycosis, among a background of acute suppurative infl ammation (Fig. 1). The patient subsequently underwent excision biopsy and the histologic study revealed an abscess. The fungal hyphae with broad and irregular branching were identifi ed by Gomori Methenamine Silver and Periodic Acid Schiff stains (Fig. 2). Case 2 A 59-year-old woman with a history of intraductal carcinoma underwent a lumpectomy and was treated with chemotherapy. Figure 1. Fine needle aspiration cytology showing numerous fungal hyphae that are morphologically consistent with zygomycosis, among a background of acute suppurative infl ammation (Diff-Quik x200). Fungal infection of the brest 67 Figure 2. Microscopic fi ndings revealing fungal hyphae with broad and irregular branching, which was identifi ed by Periodic Acid Schiff stains (arrow) (x400). Seven years post-procedure, she presented with a fi rm 4 cm mass at her right breast. On examination, the right breast was swollen and revealed two ulcers, measuring 0.8 and 2.5 cm on the upper outer quadrant. Fine needle aspiration revealed multiple septate hyphae with dichotomous branching among a background of infl ammatory exudates (Fig. 3). A wide excision was performed. The cut section of the specimens showed a green and yellow ill-defi ned lesion, measuring 4.3x3x2 cm. Microscopic fi ndings revealed multiple abscess formations containing septate fungal hyphae, similar to cytologic specimens. These hyphae were also identifi ed by Gomori Methenamine Silver and Periodic Acid Schiff stains (Fig. 4). This excision specimen also contained a small separated focus of invasive ductal carcinoma. A modifi ed radical mastectomy was performed a month later. Discussion Clinically apparent fungal infections of the breast are uncommon, even in patients who are severely immunocompromised.(1) Few cases of aspergilloma of the breast have been reported. One case reported aspergilloma in a 40-year-old woman with underlying acute myeloid leukemia,(2) and another, delayed fungal infection in a 27-year-old healthy woman. This woman underwent bilateral transareolar saline implant augmentation.(5) One review of the literature revealed that post-operative aspergillosis occurs mainly in immunocompetent patients. The surgical procedures of this review also included breast surgery.(6) Mucormycosis is 68 Sukhamwang N, Chaiwun B, Trakultivakorn H. Figure 3. Fine needle aspiration revealing multiple septate hyphae with dichotomous branching among a background of infl ammatory exudates (Diff-Quik x200). Figure 4. Microscopic fi ndings revealing multiple abscess formations containing septate fungal hyphae that are similar to cytologic specimens. These hyphae were also identifi ed by Periodic Acid Schiff stains (x200). Fungal infection of the brest 69 the common name given to several different diseases caused by fungi in the order of Mucorales. These fungi commonly infect patients who are immunocompromised or those with diabetes mellitus or trauma.(3) There are six different manifestations of mucormycosis, based on involvement of a particular body site: rhinocerebral, pulmonary, cutaneous, gastrointestinal, the central nervous system and miscellaneous. Breast involvement has not been described to date in the English literature reviewed.(4) Only one reported case of mucormycosis was found. This case was a 70-year-old woman, known to have diabetes mellitus and chronic obstructive pulmonary disease, and was on inhalation steroids and oral hypoglycemic agents. Our case of diagnosed aspergillosis had a status of post-operation lumpectomy and post-chemotherapy, which stood the risk factors of opportunistic infections. The other case of zygomycosis involved a healthy woman with no past history of breast surgery or immunosuppressive treatment. Physicians managing patients with breast implants should be aware that aspergillus infection can occur even in those who are immunocompetent.