Salmonella enterica serovar Typhi (S. Typhi) is occasionally associated with abscess formation in various organs of the body. But breast abscess by S. Typhi without the general and specific symptoms of typhoid fever is unusual. We report a case of breast abscess due to S. Typhi in a 20 year old non-lactating diabetic female without the features of typhoid fever.

Ibrahim Med. Coll. J. 2013; 7(1): 16-17

Key words: Salmonella Typhi, breast abscess, asymptomatic typhoid fever.

Address for Correspondence:Prof. J. Ashraful Haq, Department of Microbiology, Ibrahim Medical College, 122 Kazi Nazrul Islam Avenue, Dhaka-1000. E-mail: [email protected]

Introduction

Typhoid fever is a common febrile illness in many developing countries of the world including Bangladesh. It is caused by Salmonella enteric serovar Typhi (S. Typhi) and Paratyphi A, B and rarely C. Extra-intestinal manifestations of typhoid fever such as abscess due to Salmonella Typhi are not common. Infection due to S. Typhi is occasionally associated with abscess formation in various organs namely pancreas, brain, liver, spleen, muscle and breast.1-6 The abscess due to S. Typhi during typhoid is always associated with specific clinical features of enteric fever. But the presence of abscess without the general and specific symptoms of typhoid fever is unusual. We describe here a rare case of breast abscess without the presence of general and specific symptoms of typhoid fever in a young diabetic female.

Case Report

A 20 year old married non-lactating female was admitted to surgical ward on 12th May 2011 in BIRDEM General Hospital with a painful swelling of left breast for 12 days. On general examination, the patient was afebrile and her other vital parameters were stable. On local examination, there was a swelling (4x4 cm) in the left lower quadrant of the left breast which was tender, mobile and not adherent to skin. The skin over the breast was erythematous and local temperature was raised. There was no discharge from the nipple and the areola was normal. The axillary lymph nodes were not palpable.

She gave a history of high grade fever and malaise one month prior to the appearance of the swelling in the breast and treated irregularly with various antibiotics by local doctors. There was no past history of any breast disease. She had no loose motions, constipation or urinary abnormality nor had she taken any vaccination against S. Typhi. She was diabetic (type-2) for last two years and on oral anti-diabetic agents with irregular follow up for blood glucose control.

The laboratory investigations showed: hemoglobin 12.1gm/dl, total leukocyte count 14.7x109cells/l with neutrophil 65%, lymphocytes 30%, eosinophil 05%. On admission her random blood sugar was 27.1mmol/l. Fine needle aspiration cytology (FNAC) of the breast lump was negative for malignancy and features were suggestive of abscess. Incision and drainage of pus under general anesthesia was done one day after the admission and pus was sent for bacteriological culture. Culture yielded pure growth of S. Typhi which was sensitive to ciprofloxacin, ceftriaxone, cefixime, ampicillin, cotrimoxazole and nalidixic acid but resistant to azithromycin. S. Typhi was identified by standard biochemical tests and specific antisera.7 No other organism was isolated. The O and H agglutinin titers for S. Typhi were 1:80 and 1:320 respectively. The corresponding blood culture showed no growth of any organism. Based on the above findings, it was confirmed that the breast abscess was due to S. Typhi. The patient was treated with injection ceftriaxone 1g daily for 7 days followed by tablet cefixime 200 mg twice daily for another 7 days. Her blood sugar was controlled by insulin. On follow up after one month of discharge she was found asymptomatic and the abscess healed completely.

Discussion

S. Typhi causes typhoid which is a multisystem disease with generalized manifestations. Among the known extra intestinal manifestations, breast abscess due to S. Typhi is rare. In a large study conducted in India on 6250 cases of salmonellosis, 0.016% cases had focal pyogenic infection with only one case of breast abscess.8 Literature review revealed few published cases of breast abscess due to S.Typhi.9-14 Unlike our case, all the reported breast abscess cases due to S. Typhi had general and specific features of enteric fever. But our patient presented with a swelling in her left breast without fever or any other features of enteric fever. But, after the isolation of S. Typhi from the pus, on further enquiry, the patient revealed that she had an acute episode of fever one month prior to the development of breast swelling. Therefore, it appears that she might have had an attack of typhoid fever and the organism got seeded in breast tissue during the bacterimic phase of the diseases. It became reactivated because of her uncontrolled glycemic status (blood sugar level 27mmol/l) and diabetes. There were two other case reports which described abscess in testis and psoas muscle due to S. Paratyphi and S. Typhi respectively without fever or any other specific features of typhoid fever.15,16

Therefore, our case shows that S. Typhi may cause pyogenic infection in any organ of the body and people with immunosuppressive disease like diabetes may suffer from such complication without any classical clinical features of typhoid.

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