Severe Erysipelas after Treatment for Breast Cancer

Abstract

A 60-year-old woman had a modified radical mastectomy (left breast). Histology showed a grade II infiltrating ductal carcinoma, measuring 6.5 cm, as well as 11 positive lymph nodes among the 26 removed. After surgical treatment she received eight cycles of chemotherapy (FAC: 5-fluorouracil, Adriamycin, and cyclophosphamide) followed by radiotherapy (5000 cGy) to the chest wall.After 14 months of follow-up, the patient had a new primary carcinoma in the contralateral breast. She then had a right modified radical mastectomy, followed by tamoxifen at 20 mg /day. Two years after the first operation, the patient presented with hyperemia and edema throughout the left upper limb with diffuse erythematous-bullous plaques ( Fig. 1), which appeared after the first left finger was injured, also affecting the anterior region of the thorax and abdomen (Fig. 2), and associated with fever and mild toxemia. The patient was admitted for clinical treatment and was administered antibiotic therapy, including cephalothin 0.8 g /day and amikacin 1 g /day. The patient responded well, and a total regression of the lesions was observed (Fig. 3).Erysipelas is a complication that occurs with some frequency after axillary clearance. It is usually acute and is caused by streptococci or, in the most severe cases, staphylococci or Pseudomonas. The case in question is worthy of note because of the unusual aggressiveness of the infectious agent, the extension of the cutaneous lesion, and the rapid onset of the condition. The differential diagnosis of a local recurrence associated with a secondary infection was also raised. In spite of the severity of the condition, the antimicrobial regimen elicited a good response and the patient regained normal function of the affected limb within a few weeks. Figure 1. Left forearm with hyperemia, edema, and diffuse erythematous-bullous plaques.

Unsuspected Stewart–Treves syndrome clinically mimicked by apparent bullous erysipelas and a systematic review of dermatological presentations of the classical Stewart–Treves syndrome

“…In patients who undergo axillary lymphadenectomy and radiotherapy, lymphedema is a frequent sequela. Erysipelas is the main complication associated with lymphedema, but the severe bullous form is rare . In this case, the diagnostic challenge arose from the associated edema and erythema, a fact that can occur in chronic lymphedema with or without (Figure D, other patient) association of bullous erysipelas.…”