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Iranian Journal of Breast Diseases
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Research code: (IR.RUMS.REC.1405.065)
Ethics code: IR.RUMS.REC.1405.065
Bahar Noori-Rahmatabadi1 
, Hamidreza Esmaeilinadimi2 , Shiva Sadeghi meymand *3 , Mina Alipoor4 , Amir Rahnama5 , Leili Pourhosseinali2
, Hamidreza Esmaeilinadimi2 , Shiva Sadeghi meymand *3 , Mina Alipoor4 , Amir Rahnama5 , Leili Pourhosseinali2
1- Department of Anesthesiology, School of Medicine, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
2- Occupational Safety and Health Research Center, NICICO, World Safety Organization and Rafsanjan University of Medical Sciences, Rafsanjan, Iran
3- Department of Operating Room Technology, School of Allied Medical Sciences, Rafsanjan University of Medical Sciences, Rafsanjan, Iran ,Shivasame6274@gmail.com
4- Department of Anesthesiology, School of Paramedical Sciences, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
5- Non-Communicable Diseases Research Center, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
2- Occupational Safety and Health Research Center, NICICO, World Safety Organization and Rafsanjan University of Medical Sciences, Rafsanjan, Iran
3- Department of Operating Room Technology, School of Allied Medical Sciences, Rafsanjan University of Medical Sciences, Rafsanjan, Iran ,
4- Department of Anesthesiology, School of Paramedical Sciences, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
5- Non-Communicable Diseases Research Center, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
Abstract: (37 Views)
Introduction: This case report describes an exceptional presentation of bilateral breast necrotizing fasciitis in a woman without conventional predisposing factors(such as diabetes mellitus, lactation, external trauma, or immunosuppression). Unusual infectious presentations may be associated with intentional tissue injury in the context of factitious disorder, complicating early clinical and psychiatric diagnosis.
Methods: A 45-year-old premenopausal woman presented with acute bilateral breast pain, systemic toxicity, and soft-tissue necrosis. Emergency surgical exploration and extensive primary debridement were performed upon admission, followed by planned revision debridements on hospital days 2 and 5. Microbiological cultures, histopathology, and comprehensive laboratory monitoring were performed. Due to atypical, symmetrical puncture-like cutaneous lesions, psychiatric consultation was obtained and evaluated against DSM-5-TR diagnostic criteria to differentiate intentional self-injury from malingering. Written informed consent was secured, and the study was approved by the Ethics Committee of Rafsanjan University of Medical Sciences(IR.RUMS.REC.1405.065).
Results: The patient presented with severe bilateral breast pain, fever, chills, and foul-smelling discharge. Examination showed bilateral swelling, extensive erythema, skin necrosis, bullous lesions, localized sensory loss, and palpable subcutaneous gas. Surgery revealed multiple abscesses involving all four quadrants of both breasts, extensive purulent discharge, and necrosis of the skin, subcutaneous tissue, breast tissue, and deep fascia. Culture showed abundant Escherichia coli, and histopathology confirmed fascial and breast tissue necrosis with extensive neutrophilic infiltration. Vancomycin and meropenem were initiated and subsequently changed to meropenem alone according to susceptibility results. Two further debridements were performed on days 2 and 5. On the second day, hemoglobin decreased to 5 g/dL and white blood cell count increased to 19,000/mm³; two units of packed red blood cells were transfused. Multiple puncture-like lesions and simultaneous involvement of all four quadrants raised suspicion of intentional injury. Psychiatric assessment and review of previous records revealed recurrent wound infection and previous self-inflicted tissue injury, without an apparent external incentive. Psychiatric assessment supported a diagnosis of factitious disorder. Multidisciplinary management allowed discharge on hospital day 18 with psychiatric follow-up.
Conclusion: Bilateral necrotizing fasciitis of the breast may occur without recognized conventional risk factors and may be associated with intentional self-injury in the context of factitious disorder. Rapid recognition, urgent radical debridement, targeted antimicrobial therapy, and timely psychiatric evaluation are essential; early integration of liaison psychiatry is vital in atypical presentations to identify behavioral etiologies and mitigate recurrent life-threatening self-injury.
Methods: A 45-year-old premenopausal woman presented with acute bilateral breast pain, systemic toxicity, and soft-tissue necrosis. Emergency surgical exploration and extensive primary debridement were performed upon admission, followed by planned revision debridements on hospital days 2 and 5. Microbiological cultures, histopathology, and comprehensive laboratory monitoring were performed. Due to atypical, symmetrical puncture-like cutaneous lesions, psychiatric consultation was obtained and evaluated against DSM-5-TR diagnostic criteria to differentiate intentional self-injury from malingering. Written informed consent was secured, and the study was approved by the Ethics Committee of Rafsanjan University of Medical Sciences(IR.RUMS.REC.1405.065).
Results: The patient presented with severe bilateral breast pain, fever, chills, and foul-smelling discharge. Examination showed bilateral swelling, extensive erythema, skin necrosis, bullous lesions, localized sensory loss, and palpable subcutaneous gas. Surgery revealed multiple abscesses involving all four quadrants of both breasts, extensive purulent discharge, and necrosis of the skin, subcutaneous tissue, breast tissue, and deep fascia. Culture showed abundant Escherichia coli, and histopathology confirmed fascial and breast tissue necrosis with extensive neutrophilic infiltration. Vancomycin and meropenem were initiated and subsequently changed to meropenem alone according to susceptibility results. Two further debridements were performed on days 2 and 5. On the second day, hemoglobin decreased to 5 g/dL and white blood cell count increased to 19,000/mm³; two units of packed red blood cells were transfused. Multiple puncture-like lesions and simultaneous involvement of all four quadrants raised suspicion of intentional injury. Psychiatric assessment and review of previous records revealed recurrent wound infection and previous self-inflicted tissue injury, without an apparent external incentive. Psychiatric assessment supported a diagnosis of factitious disorder. Multidisciplinary management allowed discharge on hospital day 18 with psychiatric follow-up.
Conclusion: Bilateral necrotizing fasciitis of the breast may occur without recognized conventional risk factors and may be associated with intentional self-injury in the context of factitious disorder. Rapid recognition, urgent radical debridement, targeted antimicrobial therapy, and timely psychiatric evaluation are essential; early integration of liaison psychiatry is vital in atypical presentations to identify behavioral etiologies and mitigate recurrent life-threatening self-injury.
Keywords: Necrotizing fasciitis, Breast abscess, Surgical debridement, Factitious disorder, Escherichia coli, Self-inflicted injury
Type of Study: case report |
Subject:
Diagnosis, treatment, rehabilitation
Received: 2026/05/14 | Accepted: 2026/10/4
Received: 2026/05/14 | Accepted: 2026/10/4
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