A 49-year-old woman presented with arm pain for five days. The pain was located in the right armpit and sensitive to touch. The patient also reported bilateral ear pain. There were no chills, fevers, or night sweats. The patient had a normal screening mammogram five months prior. Her family history was significant for her mother with breast cancer and her father with gastric cancer. Socially, she had two cats. On physical examination, there was a painful mass below the right armpit with no overlying skin lesions. Because of the location of the mass and the family history of breast cancer, a repeat mammogram and an ultrasound were recommended. The imaging results were remarkable for a morphologically abnormal right axillary lymph node measuring 31 mm in diameter (Figure ). Ultrasound-guided biopsy was performed, and the surgical pathology exam results were consistent with cat scratch lymphadenopathy. Flow cytometry revealed no detectable monoclonal B cells or immunophenotypically aberrant T cells, which diminished the concern for malignancy. Serology was not available for this case.
A 59-year-old white woman, without having significant medical or surgical history, having familiarity with breast cancer, and not undergoing regular mammographic screening, shows the occurrence of palpable mass in the upper outer quadrant of her right breast accompanied by pain fever.\nOn physical examination, we detect the presence of a nodule of the right upper outer quadrant. This nodule has a maximum diameter of about 2 cm, it is painless, fixed on the deep layers, and hard. Moreover, palpable lymph nodes in the ipsilateral axilla and the presence of a whitish skin lesion, slightly elevated (diameter 0,5 cm) in the intermammillar region 2 cm below the angle of Luis, are observed.\nThe mammogram showed a radiopaque nodule about 20 mm, with irregular and spiculated margins ().\nOn ultrasonography mass appears a hypoechoic with irregular margins, with dimensions of 12,5 × 12,5 mm, highly suggestive of heteroplastic lesion; furthermore, enlarged lymph nodes in the contralateral axilla (diameter 35 mm) with vascular poles are identified (). On MRI, the lesion shows thin marginal spiculature and an early marked increase in the signal after contrast with a peak at the second minute, marking itself compatible with focality type 4 BIRADS (BIRADS was developed by the American College of Radiologists as a standard of comparison for rating mammograms and breast ultrasound images. It sets up a classification for the level of suspicion (LOS)—the possibility of breast cancer. BIRADS 4 means that findings do not definitely look like cancer but could be cancer. The radiologist is concerned enough to recommend a biopsy) (Figures and ).\nIt runs fine needle aspiration of bilateral axillary lymphadenopathy; in both cytology smears, it did not detect neoplastic epithelial cells. Laboratory investigations of the values of CEA and CA 15–3 are normal, as well as inflammatory markers and white cell count.\nGiven the clinical and instrumental impression of malignancy, we proceed to a complete surgical excision of the mass with quadrantectomy, ipsilateral axillary dissection, and a biopsy of contralateral axillary enlarged lymph nodes with an extemporaneous exam, the skin lesion is also removed.\nHistologically, the breast lesion is composed of a granulomatous and necrotizing inflammation (). The granulomas are composed of elements such as histiocytes with occasional multinucleated giant cells, extensive inflammatory infiltration externally, and extensive areas of confluent necrosis. A similar picture is observed on both axillary lymph nodes and skin lesion. The colors and culture test for fungi, typical and atypical mycobacteria, and immunohistochemistry for toxoplasmosis are all negative. The Warthin-Starry silver staining, specific for Barthonella henselae is negative.\nAt a later and a more accurate anamnestic investigation, the patient reveals that he had repeated contact with domestic animals and that he had observed, prior to breast pain, the appearance of a lesion such as an erythematous papule on the chest wall and on the site of a skin lesion removed surgically. After five weeks from surgery, the specific serological test is positive for Bartonella henselae.\nUpon this positivity, the patient is subjected to azithromycin for three weeks. After five weeks, posttreatment shows a subcutaneous swelling on the right arm that on ultrasound has mixed echogenicity, similar to abscess. This swelling subsides spontaneously; the chest TC shows no active pleuropulmonary disease, and abdominal ultrasound excludes hepatosplenic involvement. The patient underwent clinical and instrumental followup every six months.