Idiopathic Granulomatous Mastitis and Erythema nodosum - A Unifying Pathophysiology?

Granulomatous mastitis - Case report

INTRODUCTION AND IMPORTANCE

Idiopathic granulomatous mastitis (IGM) is a rare, benign, and chronic inflammatory breast disease with unclear etiology and no standardized treatment. It often presents as a painful breast mass that mimics breast cancer, necessitating thorough diagnostic evaluation.

CASE PRESENTATION

This report discusses a case of a 39-year-old pregnant woman with IGM associated with erythema nodosum, a poorly understood co-occurrence. Initial treatment included antibiotics and surgical drainage for an abscess. Despite multiple interventions, including corticosteroids and methotrexate, the disease persisted with recurrent episodes.

CLINICAL DISCUSSION

This case underscores the complexities of managing IGM, highlighting its association with systemic manifestations such as erythema nodosum. Current therapeutic approaches range from conservative management to immunosuppressive therapy and surgery, with outcomes varying widely.

CONCLUSION

Further studies are needed to elucidate the pathophysiology and establish optimal treatment strategies for IGM, particularly in the context of systemic involvement.

Is Idiopathic Granulomatous Mastitis a Subgroup of Systemic Lupus Erythematosus? A Preliminary Study

Objective: The study aimed to use the systemic lupus erythematosus risk probability index (SLERPI) to assess if patients with idiopathic granulomatous mastitis (IGM) meet the criteria for systemic lupus erythematosus (SLE). Methods: A total of 62 patients with IGM and 55 age- and sex-matched healthy controls (HC) were enrolled. The study included patients who were over 18 years old and had been diagnosed with IGM using a true-cut biopsy. The participants' demographic, clinical, and laboratory data were recorded in detail. The presence of autoantibodies, such as RF, CCP, C3, C4, ANA, ENA profile, and Anti-dsDNA was documented. For the detection of SLE in IGM patients, we used the SLERPI (SLE risk probability index). Results: A total of 62 patients diagnosed with idiopathic granulomatous mastitis (age 35.22 ± 8.34, BMI 27.15 ± 3.41) were compared to 55 healthy controls (age 32.54 ± 8.67, BMI 26.97 ± 3.54). The present study assessed the performance of SLERPI in IGM, and SLERPI positivity was observed in 12 out of 62 (19.4%) IGM patients. There was a significant difference in arthritis and ANA levels in the SLERPI subgroups (p < 001). Conclusions: The SLERPI index can be utilized to identify patients suspected of having systemic lupus erythematosus (SLE) in the IGM cohort.

Granulomatous mastitis with erythema nodosum: A breast cancer mimicking entity

We present the case of a 42-year-old Hispanic patient who consulted with a left breast mass that showed clinical and imaging signs of breast cancer. During preprocedural examination before needle biopsy, the patient was found to have bilateral, purplish-brown skin lesions on her lower legs, suggestive of erythema nodosum. This clinical finding raised the diagnostic suspicion of granulomatous mastitis, which was later confirmed by histopathology. Granulomatous mastitis is a rare, nonmalignant entity that should be considered in patients of childbearing age who present with a breast mass. The coexistence with erythema nodosum contributes to the clinical suspicion of granulomatous mastitis; the mechanism of this association and the optimal treatment approach remain unknown.

The Distinct Pattern of Granulomatous Lobular Mastitis with Erythema Nodosum: More Severe Conditions and Extensive Lesions

PURPOSE

Granulomatous lobular mastitis (GLM) is a benign inflammatory disease of the mammary gland with unknown etiology. Erythema nodosum (EN) is a rare, extramammary symptom of GLM. The purpose of this article was to investigate the clinical features of EN associated with GLM.

METHODS

We recruited 102 GLM patients diagnosed between December 2018 and December 2021 at Renmin Hospital of Wuhan University. The clinical characteristics and laboratory indices of the EN group (n = 12) and the non-EN group (n = 90) were compared.

RESULTS

The proportion of GLM patients with lesions involving ≥2 quadrants and high peripheral white blood cell count, absolute neutrophil count and neutrophil-to-lymphocyte ratio (NLR) was larger in the EN group than in the non-EN group (p = 0.002, 0.025, 0.014, 0.002, respectively). The duration of EN was longer in GLM patients with EN than in GLM patients without EN (p = 0.005). GLM patients with EN had more abscesses and sinus tracts than those without EN (p = 0.003, 0.038). Lesions involving ≥2 quadrants and the NLR were positively associated with the occurrence of EN (R = 0.304, 0.0302, p = 0.002, 0.002). Receiver operating characteristic curve analysis revealed that the area under the curve of the NLR was 0.770. When NLR > 5.73, the sensitivity and specificity of predicting EN were 66.67% and 87.78%, respectively.

CONCLUSION

Our findings suggest that GLM concomitant with EN suggests the presence of a more severe condition and extensive lesions.

Autoimmune rheumatic diseases associated with granulomatous mastitis

Granulomatous mastitis (GM) is a benign, inflammatory condition of the breast that mainly affects women of reproductive age. Although its pathogenesis remains unknown, previous studies revealed an association between autoimmune rheumatic diseases (ARDs) and GM in a subset of patients implicating immune-mediated mechanisms. The aim of this narrative review was to identify and describe the ARDs associated with GM to shed further light on disease pathogenesis. We conducted a comprehensive literature search of patients presenting with GM and coexisting ARDs using electronic databases. An association between GM and various ARDs has been reported, including sarcoidosis, systematic lupus erythematosus, granulomatosis with polyangiitis, psoriasis/psoriatic arthritis, familial Mediterranean fever, ankylosing spondylitis, Sjogren's syndrome, rheumatoid arthritis, and erythema nodosum, with the most common being granulomatous mastitis-erythema nodosum-arthritis syndrome (GMENA), granulomatosis with polyangiitis (Wegener's) and sarcoidosis. In addition, clinical characteristics, diagnostic and therapeutic approaches were recorded. Further research is warranted to better understand the association between GM and ARDs and raise awareness amongst rheumatologists.

Granulomatous mastitis associated with erythema nodosum: A case series of 42 patients

BACKGROUND

Granulomatous mastitis (GM) is defined by the formation of granulomatous inflammation in breast tissue. Erythema nodosum (EN) is a reactive inflammatory panniculitis characterized by erythematous subcutaneous nodules in the lower limbs. The association of GM with EN has been rarely reported. Our aim was to retrospectively review our series of patients with GM to better characterize their features and their association with EN.

METHODS

Cases histologically diagnosed as granulomatous inflammation in breast tissue between 1995 and 2020 were retrospectively reviewed.

RESULTS

Forty-two women were diagnosed with GM. The average age at diagnosis was 41.619years, and 59.5% were of South-American ethnicity. EN was associated with GM in 11.9% of the patients. Patients with EN were diagnosed earlier than isolated GM (0.4months vs 6.81months; P<.05). Ulceration in the GM was more prevalent in patients with associated EN (60% vs 14.7%; P<.05).

CONCLUSION

EN in patients with GM may reduce the evolution time and may help to diagnose this rare condition that mimics breast carcinoma.

Idiopathic Granulomatous Mastitis: Etiology, Clinical Manifestation, Diagnosis and Treatment

Idiopathic granulomatous mastitis (IGM) is a rare form of chronic inflammatory breast disease. Although it is a benign breast lesion, it may be sometimes difficult to distinguish from breast cancer. The cause of IGM is unknown, but may be associated with autoimmunity, abnormal hormone levels and infection. While the clinical manifestations of IGM involve various manifestations of inflammation, the diagnosis is principally established by histopathology, characterized by non-caseating granulomas and microabscess formation centered on the breast lobules. Therapeutic options for IGM range from observation to various medical treatments, such as steroids, immunosuppressants, and antibiotics, to surgical intervention, particularly if secondarily infected. Given that the controversy on etiology and treatment choices, we accomplished the present review through reviewing IGM-related literature published in 'Pubmed' and 'Web of science' databases during 1997 to 2020, aiming to provide the basis for rational clinical diagnosis and treatment.

Granulomatous mastitis, erythema nodosum and arthritis syndrome: case-based review

Granulomatous mastitis (GM) is a rare form of inflammatory breast condition associated with unilateral or bilateral breast pain, swelling and mass formation. Although the disease pathogenesis remains unknown, several reports have associated GM with manifestations such as erythema nodosum and occasionally with arthritis, suggesting that GM might have an autoimmune disease component. We aim to describe two cases of coexistence of GM, erythema nodosum, and arthritis. We also conducted a literature review to comprehensively assess and describe the characteristics of patients with GM, erythema nodosum, and arthritis, and identify effective treatment options. A literature review was conducted using PubMed and EMBASE, and 14 case reports/series were retrieved, with a total number of 29 patients. All patients are women and unilateral breast involvement was evident in the majority of patients. Nine patients (31%) presented with arthritis, 6 patients (20.7%) had a fever, and 6 patients (20.7%) developed the symptoms during pregnancy. All patients had normal chest radiograph and tissue cultures were negative. In most of the cases (n = 25, 86.2%), symptom improvement was observed with glucocorticoids and four patients (13.8%) underwent surgical treatment for the GM. Given the clinical characteristics of patients with GM, with erythema nodosum, with or without arthritis, and the positive response to glucocorticoids, we propose that the described phenotype represents an underrecognized systemic autoimmune disease that could be designated by the acronym "GMENA" (granulomatous mastitis, erythema nodosum, arthritis) syndrome. Further studies are needed to elucidate the pathogenesis of the syndrome.