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Figure it out fridays 

#66

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A 54 year-old lady with a background of poorly controlled type II diabetes mellitus (HbA1c = 10.8) and obesity was admitted with an atraumatic, painful right breast lump which had been present for five days.

The lump was becoming increasingly painful and she had recently developed multiple episodes fever. She was initially treated as a breast abscess with IV flucloxacillin due to raised inflammatory markers, with a white cell count (WCC) 15.25 and CRP 301.5. 

USS showed a “superficial infection with surrounding oedema but no collection or abscess”.

On the second day her White Cell Count began to fall with intravenous antibiotic therapy but her CRP continued to rise with her pain intensifying and erythema spreading. Her antibiotics were therefore changed to include IV clindamycin on microbiology advice. 

On day four of admission a repeat USS was requested due to worsening erythema. This showed “spreading skin thickening and oedema of the whole breast skin” but no demonstrable collection.

Her blood results returned later that day with a CRP of 611 and evidence acute kidney injury. In light of the blood results and her deteriorating condition she was reviewed by the breast team. 

Her LRINEC score was calculated as 9 and an urgent CT thorax was done (Shown above)

What is your diagnosis based on the hospital course and CT findings?

  1. Breast abscess

  2. Necrotizing fasciitis

  3. Cellulitis

  4. Carcinoma

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