A multidisciplinary approach to triage patients with breast disease during the COVID-19 pandemic: Experience from a tertiary care center in the developing world.

BACKGROUND: The COVID-19 pandemic has created a need to prioritize care because of limitation of resources. Owing to the heterogeneity and high prevalence of breast cancers, the need to prioritize care in this vulnerable population is essential. While various medical societies have published recommendations to manage breast disease during the COVID-19 pandemic, most are focused on the Western world and do not necessarily address the challenges of a resource-limited setting. AIM: In this article, we describe our institutional approach for prioritizing care for patients presenting with breast disease. METHODS AND RESULTS: The breast disease management guidelines were developed and approved with the expertise of the Multidisciplinary Breast Program Leadership Committee (BPLC) of the Aga Khan University, Karachi, Pakistan. These guidelines were inspired, adapted, and modified keeping in view the needs of our resource-limited healthcare system. These recommendations are also congruent with the ethical guidelines developed by the Center of Biomedical Ethics and Culture (CBEC) at the Sindh Institute of Urology and Transplantation (SIUT), Karachi. Our institutional recommendations outline a framework to triage patients based on the urgency of care, scheduling conflicts, and tumor board recommendations, optimizing healthcare workers' schedules, operating room reallocation, and protocols. We also describe the "Virtual Blended Clinics", a resource-friendly means of conducting virtual clinics and a comprehensive plan for transitioning back into the post-COVID routine. CONCLUSION: Our institutional experience may be considered as a guide during the COVID-19 pandemic, particularly for triaging care in a resource-limited setting; however, these are not meant to be universally applicable, and individual cases must be tailored based on physicians' clinical judgment to provide the best quality care.

Herpes zóster mamario como diagnóstico diferencial de la mastitis / Herpes zoster infection of the breast in the diferential diagnosis of mastitis

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[Inappropriate lactation syndrome in a Holstein heifer]. / Lactatio sine graviditate bei einer Holstein-Färse.

The present case describes an unusual lactation of a 15-month-old,unbred Holstein-Friesian heifer, which had four swollen, ampouleshaped udder quarters with milk secretion. Examination of the heifer using rectal palpation and transrectal ultrasonography revealed enlargement of the right ovary and partial replacement of original tissue by multiple cysts of variable size. Treatment of the assumed follicularcystic ovary disease was unsuccessful. At slaughter 8 months later, the ovaries were examined pathologically and a granulosa cell tumor on the right ovary was diagnosed. Udder development and lactation in cattle is regulated normally hormonally. Follicular and cystic changes and granulosa cell tumors may also display hormonal activity. Therefore, we assume one or both of these could have been the cause of the unusual lactation in this case. We thus advise careful examination of the inner reproductive tract when facing the symptom of unusual lactation in unbred heifers.

Mixed Nipple Infections Caused by Variant of BPV3 and a Putative New Subtype of BPV in Cattle.

Bovine papilloma is a chronic and proliferative skin and mucosal wart caused by Bovine papillomavirus (BPV). In June, 2013, a leaf-and flat-shaped wart disease was observed on the nipple skins in a cattle farm in Xinjiang. To diagnose the disease, we collected the diseased skins for pathological biopsy and DNA analysis by PCR amplification using a pair of degenerate primers FAP59 and FAP64. Sequencing and phylogenetic analysis showed that the infection was caused by a variant of BPV3 and putatively a new subtype of BPV (BPV/CHI-SW1, belonging to the Xi papillomavirus genus). This is the first report of mixed infection caused by variant of BPV3 and BPV (putatively new subtype) in China, and would be of importance for the molecular epidemiological study of the disease.

Molluscum contagiosum of the areola and nipple: case report and literature review.

Molluscum contagiosum is a common cutaneous infection caused by a double-stranded DNA poxvirus. Skin lesions classically present as small, flesh-colored papules with central umbilication. Lesions are frequently seen on the face, trunk, and extremities of children, or on the genitals of young adults as a sexually transmitted infection. Molluscum contagiosum on the nipple or areola has only been previously described in 4 women. We describe a woman with molluscum contagiosum on the left areola and review the clinical characteristics and histological findings of patients who developed molluscum contagiosum of the nipple or areola.

Dynamics of breast milk HIV-1 RNA with unilateral mastitis or abscess.

BACKGROUND: Mastitis and abscess in HIV-infected women increase the risk of breastfeeding transmission of HIV. Guidelines encourage women to stop breastfeeding on the affected breast and feed on the contralateral breast. However, impact of breast pathology on breast milk HIV dynamics is unknown. METHODS: HIV RNA was quantified in 211 breast milk samples collected before, during, and after a clinical mastitis or an abscess diagnosis from 38 HIV-infected women participating in a Zambian breastfeeding study. HIV RNA quantity was compared between affected and unaffected breasts over time using generalized estimating equation models. A sample of 115 women without breast pathology was selected as a control group. RESULTS: In the affected breast, breast milk HIV RNA quantity increased from the pre- to during-pathology period by log(10) 0.45 copies per milliliter [95% confidence interval (CI): 0.16 to 0.74], and after symptom resolution, HIV RNA levels were no different from prepathology levels (log10 -0.04 copies per milliliter 95% CI: -0.33 to 0.25). In the contralateral, unaffected breast, HIV RNA quantity did not significantly increase (log(10) 0.15 copies per milliliter, 95% CI: -0.41 to 0.10). Increase was more marked in women with abscess or with a greater number of mastitis symptoms. HIV RNA was not significantly different between affected and unaffected women, except at the time of diagnosis. CONCLUSIONS: Breast milk HIV RNA increased modestly in the affected breast with unilateral mastitis or abscess and returned to prepathology levels with symptom resolution. Contralateral HIV RNA was not affected. Results support guidelines encouraging feeding from the contralateral breast to minimize the risk of HIV transmission associated with unilateral breast pathology.

Breast gangrene in an HIV-positive patient.

INTRODUCTION: Breast gangrene has been reported as a complication following puerperal sepsis, breast surgery, nipple piercings, warfarin toxicity, etc. We report a case of primary breast gangrene in an HIV-positive individual which, to the best of our knowledge, is the first of its kind. CASE REPORT: A 40-year-old previously healthy woman presented with fulminating left breast gangrene. She was detected to be HIV positive. Mastectomy was performed. The detailed management of the condition is discussed. CONCLUSION: Severe necrotising infections may be initial manifestations of HIV infection and patients with such infections should be screened for HIV.

An outbreak of teat papillomatosis in cattle caused by bovine papilloma virus (BPV) type 6 and unclassified BPVs.

Out of 700 heifers at a local farm in Hokkaido, the Northern island of Japan, 560 (80%) were found to have benign teat tumors. All of the analyzed tumors were macroscopically of the flat-and-round type, and no other types such as rice-grain or frond epithelial type were found. The lesions were characterized by epithelial hyperplasia, acanthosis and hyperkeratosis. Unlike in typical fibropapilloma, fibroplasia of the underlying dermis was not observed. Bovine papilloma virus (BPV) capsid antigen and virus particles were found in basophilic intranuclear inclusions of the stratum granulosum of the epidermis by immunohistochemistry and electron microscopy, respectively. BPV-specific DNA was also detected in the lesions. By means of the polymerase chain reaction (PCR) and DNA sequencing of the PCR products, the viruses causing this outbreak were identified mainly as BPV-6 (64%), partly as unclassified BPVs (14%) and their co-infections (21%). Our findings suggest that this outbreak of benign teat tumors was associated with several BPV types.

A case of condyloma acuminata with giant and multiple lesions on the vulva and breast: successfully treated with surgical operations.

We report a case of a 24-year-old female patient with a history of giant and multiple lesions of condylomata acuminata on the vulva and breasts which were treated by surgical excision.

Giant-sized condyloma of the breast with focal acantholytic changes.

BACKGROUND: A healthy 26-year-old pregnant woman presented with a 6.0-cm exophytic mass in her left inframammary fold. The lesion was surgically excised. METHODS: Histopathologic sections of the skin lesion were reviewed in hematoxylin and eosin-stained slides. Additional sections were studied by an in situ hybridization method for human papillomavirus DNA (HPV) types 6 and 11. RESULTS: The histopathologic examination demonstrated a benign exophytic, verrucous and papillary epidermal proliferation with features of condyloma acuminatum. Reactivity to HPV DNA types 6 and 11 was demonstrated by in situ hybridization method. The epidermis adjacent to, and focally within, the neoplasm showed multiple areas of suprabasilar and intraepidermal acantholysis without dyskeratosis. CONCLUSIONS: Condylomas related to HPV 6 and 11 may be found in extragenital locations including conjunctiva, oral and nasal mucosa. To our knowledge, however, the extragenital condylomas described in the literature have not included the giant-sized variant. We describe an example of a benign, giant-sized condyloma acuminatum of the breast with nearby acantholytic alterations similar to Hailey-Hailey disease.