Ultrasound-guided microwave ablation for the treatment of idiopathic granulomatous mastitis: comparison with surgical excision.

BACKGROUND: Idiopathic granulomatous mastitis (IGM) results in notable clinical symptoms and breast deformity. This study aimed to evaluate the clinical feasibility of microwave ablation (MWA) for the treatment of IGM through comparison with surgical excision. METHODS: From June 2016 to December 2020, a total of 234 consecutive patients admitted to the hospital were retrospectively included in this study. IGM was pathologically confirmed via breast biopsy in all included patients. These patients were divided into the MWA group (n = 91) and surgical group (n = 143) based on the type of treatment. Patients in both groups received oral prednisone prior to intervention. The clinical remission rate, recurrence rate, operative pain, complications, and BREAST Q score were compared between the two groups. RESULTS: There were 340 lesions in the MWA group, and 201 lesions in the surgical group were ultimately included. Significant differences in the complete remission rate (96.7% vs. 86.7%, p = 0.020), recurrence rate (3.3% vs. 13.3%, p = 0.020), operation time (48.7±14.6 min vs. 68.1±36.4 min, p < 0.001), postoperative pain (p < 0.001) and postoperative BREAST Q score (p < 0.001) were observed between the MWA and surgical groups. CONCLUSIONS: Microwave ablation is feasible for the treatment of IGM, due to its high curative rate and low recurrence rate. Because of the minimal invasiveness of MWA and sufficient preservation of the gland and contour of the breast, patients are more satisfied with the appearance of the breast. Therefore, for patients with complex conditions requiring surgery, MWA is a good alternative treatment.

Clinical features and risk factors of bilateral granulomatous lobular mastitis.

Granulomatous lobular mastitis (GLM) is an idiopathic inflammatory breast disease that tends to recur on the same side. With the accumulation of clinical cases, it has been observed that GLM can also occur contralaterally. Currently, most studies on GLM focus on treatment methods and risk factors for ipsilateral recurrence, and there are few reports on bilateral GLM. The study aimed to summarize the clinical characteristics of patients with bilateral GLM by reviewing their clinical data, and to discuss the risk factors affecting the occurrence of bilateral GLM. A retrospective study of the medical records database of patients with GLM admitted between May 2019 and August 2022 was performed. Patients were divided into bilateral GLM group (bilateral GLM group) and unilateral GLM patients (unilateral GLM group). Demographic and clinical characteristics, treatment, and follow-up were collected and analyzed. In this study, by reviewing the clinical data of 59 cases of bilateral GLM, we found that the median time between the onset of bilateral GLM on both sides was 6.63 (0-18) months. Additionally, because of the simultaneous or interval onset on both sides, the duration of the disease was longer compared to unilateral cases. Regarding the history of external hospital treatment, it was found that about 57.63% of patients with bilateral GLM received 2 or more treatment modalities, with a higher involvement of herbal medicine. Meanwhile, by counting the clinical data of the 2 groups of patients with bilateral GLM and unilateral GLM, it was shown by univariate analysis that fertility, nipple development, absolute CD4 value, and CD4/CD8 ratio were associated with contralateral onset of GLM in both groups, with inverted nipple being an independent risk factor.

Evaluation of clinical profiles, imaging findings and antituberculosis treatment outcome in granulomatous mastitis: An Indian scenario.

BACKGROUND: The management of choice for granulomatous mastitis (GM) has yet to be determined but few studies have demonstrated that anti-tubercular treatment (ATT) could be an effective alternative therapeutic option. Hence, the objective of the current study is to determine the clinical feature, radiological imaging findings, and histopathological examination results exhibited by GM and tuberculosis (TB)-proven GM as well as to evaluate the ATT clinical outcome in GM patients. METHODS: The study was performed on 68 GM patients who were referred to the department of pulmonology by the breast clinic (from January 2018 to August 2021). Study populations were categorized into two groups GM and TB-proven GM patients and all were prescribed with standard ATT regimen and were continuously followed up. SPSS version 25 was employed for statistical assessment. RESULTS: Our study showed that 6 patients from GM and 4 patients from the TB-proven GM group got relapsed. For patients who displayed partial remission, ATT treatment was started after assessing the side effects potential. 14.6% (n = 6) and 7.4% (n = 2) patients who initially demonstrated partial remission were also completely cured. ATT treatment curable rate was determined to be 90% (n = 37) and 81.5% (n = 22) for GM and TB-proven GM patients correspondingly. Therefore, the current study demonstrated nil significant differences between groups. CONCLUSION: The current study warrants that ATT therapy could be an effective and better treatment of choice for GM patients irrespective of their clinical condition.

Immune pathogenesis of idiopathic granulomatous mastitis: from etiology toward therapeutic approaches.

Idiopathic granulomatous mastitis (IGM) is a noncancerous, chronic inflammatory disorder of breast with unknown causes, posing significant challenges to the quality of life due to its high refractoriness and local aggressiveness. The typical symptoms of this disease involve skin redness, a firm and tender breast mass and mastalgia; others may include swelling, fistula, abscess (often without fever), nipple retraction, and peau d'orange appearance. IGM often mimics breast abscesses or malignancies, particularly inflammatory breast cancer, and is characterized by absent standardized treatment options, inconsistent patient response and unknown mechanism. Definite diagnosis of this disease relies on core needle biopsy and histopathological examination. The prevailing etiological theory suggests that IGM is an autoimmune disease, as some patients respond well to steroid treatment. Additionally, the presence of concurrent erythema nodosum or other autoimmune conditions supports the autoimmune nature of the disease. Based on current knowledge, this review aims to elucidate the autoimmune-favored features of IGM and explore its potential etiologies. Furthermore, we discuss the immune-mediated pathogenesis of IGM using existing research and propose immunotherapeutic strategies for managing this condition.

Treatment modalities for granulomatous mastitis, seeking the most appropriate treatment with the least recurrence rate: a systematic review and meta-analysis.

BACKGROUND: Granulomatous mastitis (GM) is a rare, benign, inflammatory breast disease with an unknown etiology that predominantly affects women of reproductive age. The definitive treatment of GM is currently controversial; an appropriate therapeutic strategy has yet to be identified, and the disease's high recurrence rate remains. This study aims to determine the recurrence rate for each GM treatment strategy to identify the most appropriate treatment modality. METHODS: The search for relevant articles was undertaken using three international databases, including Medline, Scopus, and Web of Science. Articles published in English until the end of 2021 evaluating the recurrence rate of GM were included. Using Stata 13.0, the pooled incidence and 95% confidence interval (CI) for the recurrence rate were determined. RESULTS: Sixty-five eligible studies were included in our study. The recurrence rates of systemic steroid use, topical steroid use, antibiotic use, methotrexate use, observation, drainage, excision, antibiotic use and surgery, steroid use and surgery, antibiotic and steroid use, methotrexate and steroid use were 24% (95% CI: 21-27%), 11% (95% CI: 6-21%), 18% (95% CI: 14-22%), 13% (95% CI: 7-22%), 11% (95% CI: 7-17%), 65% (95% CI: 50-78%), 13% (95% CI: 10-16%), 23% (95% CI: 14-36%), 7% (95% CI: 5-11%), 11% (95% CI: 6-18%), and 4% (95% CI: 2-8%), respectively. Drainage had the highest recurrence rate, while combined methotrexate and steroid treatment had the lowest rate. CONCLUSION: The optimal treatment strategy for GM depends on the disease's severity, consequences, and the patient's features. The study results indicate that combination therapy is preferable for minimizing the risk of relapse and reducing treatment complications.

Ultrasound-guided vacuum-assisted excision for idiopathic granulomatous mastitis at the abscess stage.

BACKGROUND: Idiopathic granulomatous mastitis (IGM) is a rare inflammatory disease of the breast with clinical features that are often confused with those of breast cancer leading to delayed diagnosis and treatment. This retrospective study aimed to evaluate the therapeutic effectiveness and cosmetic results of drainage surgery using ultrasound-guided vacuum-assisted excision (VAE) for the treatment of IGM at the abscess stage. METHODS: The time of recovery, cases of further surgical intervention, and cosmetic results were retrospectively collected and analyzed from patients who underwent drainage with VAE or conventional drainage between October 2017 and August 2021. RESULTS: A total of 65 patients diagnosed with IGM at the abscess stage who underwent drainage surgery with VAE or conventional drainage surgery were enrolled. Overall, 38 (58.5%) underwent conventional drainage surgery and 27 (41.5%) underwent drainage with VAE. We found that patients who underwent VAE recovered much faster than those who underwent traditional drainage surgery (30.1 vs. 48.0 days). Nine (33.3%) patients in the VAE group required further surgical intervention after drainage, whereas 33 (86.8%) patients in the control group underwent another surgery to resect residual lesions. Additionally, patients in the VAE group were more satisfied with the breast appearance, mainly due to less influence of the scars and better symmetry of their breasts. CONCLUSION: Compared with conventional drainage surgery, drainage surgery using VAE for IGM patients at the abscess stage improved therapeutic and cosmetic outcomes. Furthermore, postoperative management of IGM is crucial.

Mastitis granulomatosa no caseificante: revisión retrospectiva de 61 casos / Non-caseating granulomatous mastitis: Restrospective review of 61 cases

Objetivo: determinar las características clínicas, de diagnóstico y opciones de tratamiento de la mastitis granulomatosa no caseificante. Métodos: el presente estudio es de tipo descriptivo, transversal, retrospectivo y no experimental de 61 pacientes atendidos en el Hospital Belén de Trujillo, desde enero de 2018 hasta diciembre de 2022. Fue criterio de inclusión que tengan diagnóstico histopatológico de mastitis granulomatosa no caseificante BAAR negativo. Resultados: el 93,4% afectó a mujeres en edad reproductiva (edad promedio 33 ± 7 años). La paridad, el haber dejado de dar de lactar y el uso de anticonceptivos se asociaron en forma estadísticamente significativa con la mastitis (p ≤ 0,05). En su mayoría afectó la mama izquierda. La tumoración varió entre 3 y 11 cm con un tamaño promedio de 5,0 ± 2 cm. En el 49,2% la tumoración se acompañó de una o más fistulas. El 38,5% hizo uso de anticonceptivos hormonales. El cultivo de 25 tejidos mamarios biopsiados fue negativo. El estudio ecográfico fue categorizado en el 91,8% como BIRADS 2 y 3. El 67,2% mejoró con tratamiento antituberculoso, aun cuando no había evidencia de BAAR positivo. El 32,8% mejoró con tratamiento diverso con antibióticos y sin antibióticos. Conclusiones: este tipo de mastitis se presenta en la etapa reproductiva de la mujer, pero después del periodo de lactancia. Los anticonceptivos hormonales podrían predisponer a esta afección. Su manejo es variable, puede hacerse con antituberculosos, antibióticos comunes y en casos extremos resección quirúrgica.(AU)

Objective: To determine the clinical characteristics, diagnosis and treatment options of non-caseating granulomatous mastitis. Methods: The present study is descriptive, cross-sectional, retrospective and non-experimental of 61 patients treated at the Hospital Belen of Trujillo, from January 2018 to December 2022. The inclusion criterion was that they have a histopathological diagnosis of granulomatous mastitis without caseification Acid-Fast Bacilli negative. Results: 93.4% affected women of reproductive age (age average 33 ± 7 years). Parity, having finishing breastfeeding and the use of contraceptives were associated in a statistically significant way with matitis (p ≤ 0.05). It mostly affected the left breast. The tumor varied between 3 and 11 cm with an average size of 5 ± 2 cm. In 49.2%, the tumor was accompanied by one or more fistulas. 38.5% used hormonal contraceptives. The culture of 25 biopsied breast tissues was negative. The ultrasound study was categorized in 91.8% as BIRADS 2 and 3. 67.2% improved with anti-tuberculosis treatment even though there was no evidence of positive AFB. 32.8% improved with diverse treatment, with antibiotics and without antibiotics. Conclusions: This type of mastitis occurs in the reproductive stage of the woman, but after the lactation period. Hormonal contraceptives could predispose to this condition. Its management is variable, it can be done with anti-tuberculosis drugs, common antibiotics and in extreme cases surgical resection.(AU)

Mastitis granulomatosa: experiencia diagnóstica y terapéutica multidisciplinaria del Hospital Argerich de Buenos Aires / Granulomatous mastitis: Multidisciplinary diagnostic and therapeutic experience at Argerich Hospital in Buenos Aires

Introducción: la mastitis granulomatosa es una enfermedad inflamatoria crónica que se presenta como un tumor mamario doloroso, asociado a abscesos y fístulas, que puede simular un carcinoma. Su etiología no es clara y se postula un mecanismo autoinmune modulado por el bacilo Corynebacterium. No existen guías diagnósticas ni algoritmos terapéuticos. En nuestro estudio analizamos las presentaciones clínicas, imágenes, cultivos y hallazgos patológicos junto con los tratamientos, resultados y evolución. Material y métodos: realizamos un estudio descriptivo, retrospectivo y observacional de las pacientes con diagnóstico de mastitis granulomatosa tratadas en nuestro hospital en el periodo 2017-2022. Resultados: se evaluaron 51 pacientes con una edad media de 38,1 años; que habían tenido embarazos y lactancia, 88,2%. Clínica: tumor palpable abscedado y/o fistulizado, 74,5%; tumor palpable doloroso 13,8%; tumor asintomático, 11,7 %; eritema nodoso, 11,7%; imágenes BIRADS 4-5: 82,3%; tamaño promedio: 3,54 cm. Patología: vacuolas quísticas asociadas a Corynebacterium en 24 biopsias (47,1%); bacteriología: cultivos positivos para Corynebacterium en 13 de 47 muestras (27,6%). Tratamiento: antiobioterapia 92,1%; inmunosupresión, 78,4% y tratamiento quirúrgico 60,7 %. Tiempo medio de inmunosupresión con corticoides 7,09 meses y con metotrexato 9,27 meses. Complicaciones: 9,8%; secuelas estéticas: 39,2% tiempo libre de enfermedad: 14,04 meses. Recurrencias: 13,7 %. Conclusiones: la búsqueda bacteriológica y patológica del Corynebacterium junto a un abordaje multidisciplinario es esencial para un tratamiento a medida del paciente en pos de lograr el mayor éxito terapéutico.(AU)

Introduction: Granulomatous mastitis is a chronic inflammatory disease that presents as a painful breast mass, associated with abscesses and fistulas, which can mimic carcinoma. Etiology is still unclear, and an autoimmune response related to Corynebacterium is postulated. There are no diagnostic guidelines or therapeutic algorithms. In our study we analyzed the clinical presentations, images, cultures, and pathological findings together with the treatments, results, and evolution. Material and methods: We carried out a descriptive, retrospective, and observational study of patients diagnosed with granulomatous mastitis treated in our hospital in the period 2017-2022. Results: 51 women. Average age 38.1 years. Pregnancies and Lactation 88.2%. Clinic: Abscessed and/or fistulized palpable mass 74.5%, painful palpable mass 13.8%. Asymptomatic mass 11.7%. Erythema Nodosum 11.7% BIRADS images 4/5: 82.3%. Average size: 3.54 cm. Pathology: Cystic vacuoles associated with Corynebacterium in 24 biopsies (47.1%). Bacteriology: positive cultures for Corynebacterium in 13 of 47 samples (27.6%). Treatment: antibiotic therapy 92.1%, immunosuppression 78.4%, surgical treatment 60.7%. Mean time of immunosuppression with corticosteroids 7.09 months and with methotrexate 9.27 months. Complications: 9.8% Aesthetic sequelae: 39.2% Disease-free time: 14.04 months. Recurrences: 13.7%. Conclusions: The bacteriological and pathological search for Corynebacterium and a patient tailor made multidisciplinary approach is essential to achieve therapeutic success.(AU)

Recurrent Idiopathic Granulomatous Mastitis: A Case Report.

Idiopathic granulomatous mastitis is a rare benign breast disease of unknown aetiology mostly presenting as a breast abscess but not responding to usual conservative management with incision and drainage and frequently mimics breast cancer. We present a case 31-year-old female presented with complaints of right breast pain and redness who was initially diagnosed and treated as a case of breast abscess with repeated incision and drainage and antibiotics but did not improve. Later histopathology revealed granuloma with giant cell reaction and the patient was given a trial of steroids which showed no improvement. Wide local excision with a long course of broad-spectrum antibiotics was performed which led into remission. This case report highlights the importance of considering idiopathic granulomatous mastitis as differentials in non-responding breast abscesses. Histopathology for diagnosis and trial of wide local excision with a long course of broad-spectrum antibiotics as treatment may be done for management. Keywords: antibiotics; case reports; granuloma; mastitis.

Refractory and Recurrent Idiopathic Granulomatous Mastitis Treatment: Adaptive, Randomized Clinical Trial.

BACKGROUND: Idiopathic granulomatous mastitis (IGM) is mostly described as an autoimmune disease with higher prevalence among Middle Eastern childbearing-age women. This study aimed to evaluate the best treatment of choice in patients with resistant or recurrent IGM. STUDY DESIGN: Patients with established recurrent or resistant IGM who were referred to the Breast Cancer Research Center from 2017 to 2020 were randomly assigned to either one of the following treatment groups: A (best supportive care), B (corticosteroids: prednisolone), and C (methotrexate and low-dose corticosteroids). This adaptive clinical trial evaluated radiological and clinical responses, as well as the potential side effects, on a regular basis in each group, with patients followed up for a minimum of 2 years. RESULTS: A total of 318 participants, with a mean age of 33.52 ± 6.77 years, were divided into groups A (10 patients), B (78 patients), and C (230 patients). In group A, no therapeutic response was observed; group B exhibited a mixed response, with 14.1% experiencing complete or partial responses, 7.7% maintaining stability, and 78.2% experiencing disease progression. Accordingly, groups A and B were terminated due to inadequate response. In group C, 94.3% achieved complete response, 3% showed partial remission, and 2.7% had no response to therapy. Among the entire patient cohort, 11.6% tested positive for antinuclear antibodies, 3.5% for angiotensin-converting enzyme, and 12.3% for erythema nodosum. Notably, hypothyroidism was a prevalent condition among the patients, affecting 7.2% of the cohort. The incidence of common side effects was consistent across all groups. CONCLUSIONS: The most effective treatment option for patients with recurrent or resistant IGM is a combination therapy involving steroids and disease-modifying antirheumatic drugs such as methotrexate.

Idiopathic Granulomatous Mastitis.

Idiopathic granulomatous mastitis (IGM) is a rare, benign inflammatory disorder of the breast that is often underrecognized. The exact etiology and pathophysiology are unknown, but milk stasis is felt to play a role. Classically, this condition is noninfectious, but many cases are noted to be associated with Corynebacterium species. Most patients affected are parous women with a mean age of 35, and many have breastfed within five years of diagnosis. Patients typically present with a painful mass and symptoms of inflammation, and these features can sometimes mimic breast cancer. Biopsy is needed to make a definitive diagnosis, and noncaseating granulomas are found on core biopsy. Many patients have a waxing and waning course over a period of six months to two years. Goal of treatment is to avoid surgery given poor wound healing, high risk of recurrence, and poor cosmetic outcomes. Medical treatment is preferred and includes observation, antibiotics, steroids, and immune modulators such as methotrexate. In more recent years, topical and intralesional steroids have become the treatment of choice, with similar outcomes to oral steroids.

18 F-FDG PET/CT Imaging of Idiopathic Granulomatous Mastitis.

ABSTRACT: A 43-year-old woman, who presented with a suspected left breast abscess, underwent serial ultrasounds, which demonstrated inflammatory changes that were nonresponsive to antibiotics and which spread to the contralateral breast. 18 F-FDG PET/CT demonstrated diffuse heterogeneous intense FDG uptake in both breasts with reactive axillary nodes. Breast biopsy confirmed granulomatous inflammation, and overall findings were consistent with idiopathic granulomatous mastitis. In the absence of histological analysis, idiopathic granulomatous mastitis is an important differential diagnosis to consider for bilateral abnormal breast uptake, and early recognition can facilitate prompt commencement of treatment.

The Effect of Local Steroid Administration on Idiopathic Granulomatous Mastitis: A Systematic Review andMeta-Analysis.

INTRODUCTION: Idiopathic granulomatous mastitis (IGM) is a rare, benign inflammatory breast disease. Corticosteroids and surgery are the primary treatment options, and a growing number of publications have shown the effectiveness of local steroid administration (intralesional injection and topical corticosteroids). However, less is known about the specific details and effects of this treatment approach. The purpose of this meta-analysis was to summarize the details and evaluate the efficacy of local steroid administration for IGM. METHODS: The PubMed, Embase, Cochrane Library, and SinoMed databases were systematically searched from inception to July 2023 to identify relevant randomized controlled trials. The quality of the included studies was assessed, and meta-analysis and subgroup analysis were conducted to obtain the pooled effect sizes of the outcomes of interest. RESULTS: Eight trials comprising 613 patients were included. Local steroid administration included intralesional injection and topical steroid ointment, and control groups were mainly given systemic therapy (oral steroid) and surgical treatment. The meta-analysis showed that local steroid administration had a significant effect on the response rate (risk ratio [RR] = 1.35, 95% CI = [1.14-1.59], P = 0.0004). The incidence of side effects was also lower than that of systemic treatment (RR = 0.24, 95% CI = [0.13-0.43], P＜0.0001). There was no difference in the recurrence rate (RR = 0.8, 95% CI = [1.42-1.51], P = 0.48). CONCLUSIONS: Local steroid administration can increase the RR and decrease the incidence of side effects for IGM patients. There is no significant difference in the recurrence rate between the local steroid administration group and the control group. Further studies are needed to identify the effect in different stages and among pregnant women.

Rotational gland dissection for refractory granulomatous mastitis: A single-center retrospective study.

BACKGROUND: Refractory granulomatous mastitis (RGM) is a chronic benign breast disease that commonly occurred in women of childbearing age and is usually treated with surgery, with numerous cases suffering from unsatisfied postoperative recovery of breast shape, high rates of surgical complications, and even high recurrence. This study tries to evaluate the efficacy of an innovative surgical procedure, the rotational gland dissection for the treatment of RGM. METHODS: 129 patients with RGM who underwent surgical treatment at the Second Affiliated Hospital of Xi'an Jiaotong University between Apr. 2017 and May. 2021 were retrospectively included in this study. The article analyzed the age, local symptoms, lesion location, and size, days in hospital, recurrence rate, and satisfaction rate of the patients. RESULTS: Patients ranged in age from 19 to 58 years, with a median age of onset of 32 years. In 63 patients (48.84%), their lesions coverage exceeded two quadrants, and 52.71% of patients had lesions larger than 10 cm2. The average days in hospital of patients was 7.5 days, and 85.27% of them were satisfied with their post-surgery breast appearance. Within the median follow-up of 56 months, only 3.10% of patients experienced a recurrence of mastitis on the operation side. CONCLUSION: This novel surgical procedure we created is an effective treatment for RGM with a high success rate, high patient satisfaction, and low recurrence rate, and is significantly superior to other studies for it has the largest sample size and longest follow-up in this field.

Granulomatous lobular mastitis co-existing with ductal carcinoma in situ: Report of three cases and review of the literature.

Granulomatous lobular mastitis (GLM) is a benign and infrequent chronic breast ailment. Although this lesion can be clinically and radiographically mistaken for early-onset breast cancer, it is a rare occurrence for the two to coexist. This report describes three such cases. In all three patients, the primary signs and symptoms were related to the formation of diffuse breast masses or abscesses. Breast ultrasound and MRI revealed glandular edema and dilated breast ducts. The biopsies of all lesions exhibited both granulomatous inflammation confined to the lobules of the breast, abundant interstitial inflammatory cell infiltrates, and apparently cancerous cells located in dilated ducts with intact basement membranes. The surgically excised specimens confirmed the diagnosis of GLM and ductal carcinoma in situ (DCIS) in all three patients who underwent breast mass resection. By clinical imaging and clinical manifestations, GLM may obscure a concurrent DCIS, as highlighted by the cases reported herein.

Imiquimod as a new treatment in refractory idiopathic granulomatous mastitis: report of two cases.

INTRODUCTION: Idiopathic granulomatous mastitis (IGM) is a rare chronic inflammatory lesion of the breast that mimics breast cancer or infection. Immunological pathogenesis is strongly suggested for the disease. REASON FOR THE REPORT: The treatment remains controversial, comprising a spectrum from observation or NSAIDs to immunosuppressive agents and surgery. Intractable cases are not uncommon and represent a major treatment challenge. Therefore in this study, we examine the effect of a topical immunomodulator agent, imiquimod, on refractory IGM. Patient 1 had IGM for 9 months and had not responded to the existing treatments. She responded to a 7-week course of imiquimod. In patient 2, the disease had begun 4 months sooner and had been resistant to all treatments; it responded to imiquimod after 4 weeks. Ulcers appeared on the skin of both patients but resolved safely. OUTCOME: Both patients were very satisfied with the results. Imiquimod can be an appropriate local treatment with limited adverse effects in refractory IGM. We propose similar studies to assess the efficacy of imiquimod in IGM further, paying attention to the possibility of developing skin wounds.

Idiopathic Granulomatous Mastitis Associated with Erythema Nodosum in a Pregnant Woman.

A 32-year-old woman at 17 weeks' gestation presented with fever and a 1-week history of an acute nodular eruption involving her legs, along with bilateral ankle and knee pain. She also had had a recurrent right breast abscess for 2 months for which she had been treated with oral antibiotics and surgical drainage, but with slight improvement. Cultures of the abscess showed no bacteria or fungi. She had no history of tuberculosis, sarcoidosis, trauma to the breast, or a family history of breast pathology. Cutaneous examination revealed multiple, tender, erythematous, subcutaneous nodules on her legs (Figure 1) and an ill-defined tender mass involving the inferior quadrant of the right breast without nipple discharge or retraction. There was a scar with drainage on her right breast (Figure 2). There were no regional lymphadenopathies. Left breast and left axilla examination was unremarkable. Significant laboratory findings included an erythrocyte sedimentation rate of 54 mm/hour (normal levels [NL] < 20 mm/hour), an elevated C reactive protein at 148 mg/L (NL < 5 mg/L), and a high level of white blood cells averaging 15,000 elements/mm3 (NL < 10,000/mm3).