Tinea and Erysipelas carcinomatosum

ARTICLE

Figures 1 and 2 show skin changes in the breasts of two patients. A 74-year-old patient presented a slightly scaly eythematous lesion on and around the left areola that had developed several weeks previously (Fig. 1). The lesion enlarged despite a topical glucocorticoid treatment and the patient was referred to us. The second patient initially turned to a plastic surgeon for breast reduction. The surgeon refused the operation, interpreting the skin changes as erysipelas (Fig. 2) and sent the patient to our department for antibiotic therapy. The 44-year-old patient remembered having developed a persistently expanding hot erythema on the right lateral breast with the aspect of peau d'orange for 8 weeks. She reported feeling heaviness and tension, fever or lymph node swelling were not present.

Breast cancer is a common and important condition. All physicians have a duty to detect and diagnose breast cancer. Mostly, the disease lies in the province of the surgeon or gynecologist. The dermatologist examining the entire skin, however, also has the opportunity by inspection and palpation to detect early breast cancer [1]. Some breast cancers, for example mammary Paget's disease or inflammatory breast cancer clinically present initially as skin disease. However, simulators of both conditions exist and definitive diagnosis depends on histopathologic examination. We present two patients with clinical findings, one typical of Paget's disease (Fig. 1), and the other of erysipelas (Fig. 2). The clinical judgment was militated by the report of the dermatopathologist in both patients. The scaly and erythematous skin changes of the first patient turned out to be a tinea. Trichophyton rubrum was cultured from skin scales and PAS positive septate hyphae could be demonstrated in a skin biopsy (Fig. 3A, B). One possible source for the tinea was the longstanding onychomycosis of the toes, which was seen, too.

A deep skin biopsy of the second patient, who presented with redness and swelling of the right lateral breast, revealed crowded neoplastic cells in widened lymphatic vessels (Fig. 4A). Immunohistochemically, these cells stained positively for the pan-cytokeratin marker AE1/AE3 (Fig. 4B). Erysipelas carcinomatosum [2-5] (inflammatory breast cancer) secondary to a ductal breast cancer was finally diagnosed, and the patient was referred to the department of gynecology. There, 3 cycles of chemotherapy with epirubicin and cyclophosphamid were given, followed by mastectomy and axillary lymphadenectomy. All analyzed lymph nodes were tumor-free, the patient again received 3 cycles of chemotherapy and is doing well 14 months after the diagnosis of breast cancer was made.

These two examples emphasize that dermatologists and dermatopathologists must be aware of breast cancer. Therefore, in any case of inflammatory breast disease, a representative biopsy has to be taken.

References

1. Bork K. Haut und Brust. 1995; Gustav Fischer Verlag.

2. Lookingbill DP, Spangler N, Helm KF. Cutaneous metastases in patients with metastatic carcinoma: a retrospective study of 4,020 patients. J Am Acad Dermatol 1993; 29: 228-36.

3. Lookingbill DP, Spangler N, Sexton FM. Skin involvement as the presenting sign of internal carcinoma. A retrospective study of 7,316 cancer patients. J Am Acad Dermatol 1990; 22: 19-26.

4. Brownstein MH, Helwig EB. Patterns of cutaneous metastasis. Arch Dermatol 1972; 105: 862-8.

5. Cox SE, Cruz PD Jr. A spectrum of inflammatory metastasis to skin via lymphatics: three cases of carcinoma erysipeloides. J Am Acad Dermatol 1994; 30: 304-7.