Breast abscess due to Salmonella is an uncommon but well recognized extra intestinal complication of enteric fever. Salmonella species is commonly identified as a gastrointestinal pathogen causing bacteremia but inappropriately treated cases can lead to dissemination in multiple organ systems resulting in localized abscess formation. Case reports have been described in literature about extra-intestinal abscesses caused by S. enterica serotype Typhi and Paratyphi. Whilst recently, there has been an upsurge in the frequency of cases related to Salmonella breast abscess, reason may be due to emergence of resistant Salmonella strains. So, acknowledging prevalence of breast abscess due to Salmonella is of utmost important for complete cure.

Keywords: Abscess, Breast, Salmonella

INTRODUCTION

Breast abscess is a localized, painful collection of purulent material in breast tissue mostly affecting women of reproductive age group. They are predominantly lactational but non-lactational abscesses are also seen in older women. Although Staphylococcus aureus is the most common pathogen, other microorganisms can be found for example Streptococcus species, Coagulase Negative Staphylococcus and anaerobes such as Peptostreptococccus and Bacteroides [1]. Recent studies and various case reports highlighting breast abscess due to Salmonella spp. has been noted. In developing countries where enteric fever is endemic, Salmonella should be considered one of the main causes of breast abscess and treatment options should be decided accordingly. Usually uncomplicated abscesses show effective clearance with single course of oral antibiotic agents together with surgery but reviews have recommended azithromycin as a drug of choice especially in the presence of fluoroquinolones resistance. This review aims to summarize the available various case reports studies related to breast abscess due to Salmonella spp.

DISCUSSION

Although Staphylococcus aureus is the most common pathogen but the incidence of Salmonella breast abscesses have been reported in up to 0.9% of cases [2]. Salmonella species are majorly responsible for significant morbidity and mortality in developing countries. It is capable of forming localized abscesses in various organs such as subcutaneous tissue, muscles and skin. The pathogenesis is not well established but possible causes may be hematogenous route and lymphatic spread from gastrointestinal tract. The major risk factors are extremes of ages, immune suppression, underlying malignancy, intravenous drug abuse and previous trauma [3].

On analyzing the literature available on breast abscesses due to Salmonella spp., it was noted that most of the patients were immunocompetent non lactating females between the age group of 23-45 years [4].  The incidence of breast abscess in typhoid patients was observed to be 0.3% in 1930 by Klose and Sebening and 0.5% in 1937 by Pezinski in a study of 1,196 cases of typhoid. Other authors have also reported similar cases of unilateral breast abscess due to Salmonella Typhi as well as bilateral breast abscesses (Table 1). K Jayakumar et al. reported S. typhi from unilateral breast abscess in a 40-year old non-lactating woman [5]. Similarly, Viswanathan et al. [6] have reported isolation of S. Typhi from a 42-year-old non-lactating female patient with unilateral breast abscess [6]. Singh S et al reported S. Typhi from a 35-year-old non-lactating female patient with bilateral breast abscess [7]. Similar bilateral painful lump in a 29 year old female was reported by Singh G et al. that grew S. Typhi. Kumar et al. and Murugesan et al. reported cases of S.typhi in diabetic patient [8-10]. Cases were also reported from countries like France and USA [11,12]. Though Salmonella breast abscess is a complication of enteric fever seen exclusively in females, Nada [3] have reported the isolation of S. enteritidis from a 70-year-old male patient with unilateral breast abscess.

Unlike Salmonella Typhi, breast abscess due to Salmonella paratyphi is a rare complication of enteric fever. Fernando et al. had reported the first case of recurrent breast abscess caused by Salmonella enterica serotype paratyphi. A while Siddesh et al. reported chronic case of breast abscess by Salmonella Paratyphi A from India [13,14]. Ghadage et al. had reported a case of recurrent breast abscess by Salmonella Paratyphi A in a 31-year-old non lactating female [15]. Recent cases reported by Agarwal et al. showed complete resolution of unilateral breast abscess with Azithromycin [16]. But further research is required to understand the effective management of breast abscess by azithromycin and other newer agents. Among non typhoidal salmonellae, Razeq et al. and Edelstein et al. had isolated Salmonella landweisser and Salmonella serogroup B respectively [17,18]. Benwan et al. reported a very rare serotype, Salmonella enterica serotype Poona, which was associated with erythema nodosum [19].

Irrational use of antibiotics had raised the incidence of resistant Salmonella cases too. Kumar et al. reported a multidrug-resistant typhoid with breast abscess [20]. Elumalai et al. observed fluoroquinolones resistance mechanism in S. typhi from a breast abscess case [21]. The study showed high level resistance in S.typhi to nalidixic acid (minimum inhibitory concentration [MIC]>512 μg/ml) and ciprofloxacin (MIC 8 μg/ml).

Hence, any breast abscess in an immunocompetent female with or without a history of enteric fever having no other predisposing factors must be evaluated, keeping the possibility of a Salmonella breast abscess. The pus aspirated must be sent for bacteriological culture. Failure to perform microbiological test might lead to missed diagnosis [22-24].

This review highlights the need for understanding the local epidemiology of enteric fever and its complications. Complete assessment of the patient including breast imaging, microbiological culture and drug susceptibility report are essential for appropriate management of rare complications of enteric fever like breast abscesses. Physicians must be aware of the management and should make referrals of patient for which resolution does not occur rapidly with a single course of antibiotic therapy. Delay in diagnosis and appropriate treatment can have serious consequences on residual morbidity.

ACKNOWLEDGEMENT

I would like to acknowledge technicians working in Microbiology department for literature search.

1.     Dixon JM (2006) ABC of breast diseases. Oxford, England: Blackwell, pp: 19-23.

2.     Edelstein H (1993) Breast abscess due to Salmonella serogroup B, serotype reading, in a young nonpuerperal woman. Clin Infect Dis 17: 951-952.

3.     Brncic N, Gorup L, Strcic M, Abram M, Mustac E (2012) Breast abscess in a man due to Salmonella enterica serotype Enteritidis. J Clin Microbiol 50: 192-193.

4.     Lalitha MK, John R (1994) Unusual manifestations of Salmonellosis - A surgical problem. Q J Med 87: 301-309.

5.     Jayakumar K, Appalaraju B, Govindan VK (2003) An atypical presentation of Salmonella typhi - A case report. Indian J Med Microbiol 21: 211-212.

6.     Viswanathan R, Shah Ah, Nagori IF, Gupta MK (2003) Salmonella typhi in breast abscess case reports. Bombay Hosp J 45: 3.

7.     Singh S, Pandya Y, Rathod J, Trivedi S (2009) Bilateral breast abscess: A rare complication of enteric fever. Indian J Med Microbiol 27: 69-70.

8.     Singh G, Dasgupta M, Gautam V, Behera A, Ray P (2011) Bilateral breast abscesses due to Salmonella Enterica Serotype Typhi. J Glob Infect Dis 3: 402-404.

9.     Kumar ES, Selvam RE, Ramesh SS (2012) Salmonella enterica serovar Typhi in breast abscess: A case report. Indian J Pathol Microbiol 55: 608-609.

10. Murugesan N, Alagar samy R, Viswanathan MS, Anbazhagan A (2016) A rare case of breast abscess due to Salmonella Typhi. Int J Curr Res Rev 8: 10-12.

11. Delori M, Abgueguen P, Chennebault JM, Pichard E, Fanello S (2007) Breast abscess with Salmonella Typhi and review of the literature. J Gynecol Obstet Biol Reprod (Paris) 36: 709-712.

12. Vattipally V, Thatigotla B, Nagpal K, Saraiya R, Henry M, et al. (2011) Salmonella Typhi breast abscess: An uncommon manifestation of an uncommon disease in the United States. Am Surg 77: E133-E135.

13. Fernando S, Molland JG, Gottlieb T (2012) Failure of oral antibiotic therapy, including azithromycin, in the treatment of a recurrent breast abscess caused by Salmonella enterica serotype Paratyphi A. Pathog Glob Health 106: 366-369.

14. Siddesh G, Sumana MN (2012) A case of breast abscess due to Salmonella Paratyphi A. Int J Health Allied Sci 1: 109-111.

15. Ghadage DP, Wankhade AB, Mali RJ, Bhore AV (2014) Recurrent breast abscess due to Salmonella Paratyphi A: An unusual case. Int J Res Med Sci 2: 1236-1238.

16. Agrawal S, Yadav VS, Srivastava A, Kapil A, Dhawan B (2018) Breast abscess due to Salmonella Paratyphi A: Case reports with review of literature. Intractable Rare Dis Res 7: 130-133.

17. Razeq JH, Glenn A, Thomas G, Sholes A (2000) First human case of Salmonella enterica serotype Landwiesser recovered from breast fluid. J Clin Microbiol 38: 4300.

18. Edelstein H (1993) Breast abscess due to Salmonella serogroup B, serotype reading, in a young nonpuerperal woman. Clin Infect Dis 17: 951-952.

19. Al Benwan K, Al Mulla A, Izumiya H, Albert MJ (2010) Erythema nodosum and bilateral breast abscesses due to Salmonella enterica serotype Poona. J Clin Microbiol 48: 3786-3787.

20. Kumar PD (1998) Breast abscess: A rare complication of multiresistant typhoid fever. Trop Doct 28: 238-239.

21. Elumalai S, Seetharaman S (2016) Molecular analysis of fluoroquinolone resistance in Salmonella enterica serovar Typhi from a breast abscess case. Indian J Pathol Microbiol 59: 261.

22. Banu A, Hassan MM, Anand M (2013) Breast abscess: Sole manifestation of Salmonella Typhi infection. Indian J Med Microbiol 31: 94-95.

23. Sood S (2015) Breast abscess by Salmonella Paratyphi A: Case report and literature review. J Clin Diagn Res 9: DD03-DD04.

24.  Baran I, Aksu N, Aksoy A (2016) Breast abscess due to Salmonella Typhimurium in a patient with rheumatoid arthritis: A case report. BMC Infect Dis 16: 348.