PMC8448995_01
(a) Clinical pictures of the patient's bilateral necrotizing scleritis. (b) Discharge from her nipples (arrow). (c) Pale erythema (arrowhead) and a skin ulcer (arrow) on the right breast.
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She was diagnosed with bilateral necrotizing scleritis (Figure 1(a)) and was referred to our department to assess the involvement of an autoimmune disease. Subcutaneous induration was observed in both breasts, along with discharge from the nipples (Figure 1(b)). Pale erythema and a skin ulcer were found on the right breast (Figure 1(c)). A biopsy of a skin ulcer on the right chest wall (from the location of the arrow in Figure 1(c)) showed granuloma formation, including lymphocytes and plasma cells outside the blood vessels without vasculitis.
(a) Computed tomography showing tumor-like lesions in the patient's breasts (right, arrowhead; left, arrow) on the first admission. (b) Whole-body computed tomography revealing pulmonary consolidation in the right lower lobe (circle). (c) A small nodule in the right breast (arrow), and (d) recurrence of right maxillary sinusitis (arrow) during the second admission.
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Computed tomography (CT) of the thorax indicated no abnormalities in the lung fields; however, tumor-like lesions were found in her breasts (Figure 2(a)). Cytology revealed infiltration of inflammatory cells, which were mainly lymphocytes and agglomeration of epithelioid cells containing multinucleated giant cells, without malignant cells. Core needle biopsy of her left breast (from the location of the arrow in Figure 2(a)) showed inflammatory cell infiltration consisting of lymphocytes with surrounding fibrotic lesions without vasculitis. The PR3-ANCA titer had increased to 26.5 U/mL, and whole-body CT revealed pulmonary consolidation in the right lower lobe (Figure 2(b)) and a small nodule in the right breast (Figure 2(c)) as new lesions with recurrence of maxillary sinusitis (Figure 2(d)). A biopsy of the small nodule in the right breast (from the location of the arrow in Figure 2(c)) showed lymphocyte-dominant inflammatory cell infiltration and granulomas with polynuclear giant cells around the blood vessels in the subcutaneous fat layer, which can be interpreted as necrotizing granulomatous vasculitis (Figures 4(a) and 4(b)).
Mediolateral oblique (a, b) and craniocaudal (c, d) mammography demonstrates a round, microlobulated, and high-density mass lesion in the right breast (a, c) and circumscribed, round, and high-density mass lesion in the left breast (b, d).
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Mammography demonstrated a round, microlobulated, and high-density mass lesion in the right breast, which was classified as category 4, and a 7.5 cm circumscribed, round, and high-density mass lesion in the left breast, which was classified as category 3 (Figure 3).
Histopathological findings of the biopsy of the nodule in the right breast. Lymphocyte-dominant inflammatory cell infiltration and granulomas with polynuclear giant cells (arrow) are visible around the blood vessels in the subcutaneous fat layer with hematoxylin and eosin staining (a). Verhoeff's Van Gieson staining shows destruction of the elastic plate (b) (arrowheads).
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A biopsy of the small nodule in the right breast (from the location of the arrow in Figure 2(c)) showed lymphocyte-dominant inflammatory cell infiltration and granulomas with polynuclear giant cells around the blood vessels in the subcutaneous fat layer, which can be interpreted as necrotizing granulomatous vasculitis (Figures 4(a) and 4(b)).