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A CASE PRESENTATION Dr. A. UMEH. Name: Mrs. XY. Age: 36 years Address: Abakpa Nike Enugu. Occupation: House-wife Religion: RCM PC: Lump in Rt breast – 5months duration.
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Name: Mrs. XY. Age: 36 years Address: Abakpa Nike Enugu. Occupation: House-wife Religion: RCM PC: Lump in Rt breast – 5months duration
HxPC: Known retroviral disease patient confirmed 2years ago when the medical team (UNTH) managing her late husband confirmed RVD positive carried out a case tracing. She had since then been managed on lamivudine, stavudine and nevirapine all daily b.d.) at the hospital’s RVD clinic.
Patient presented (9/1/06) at our surgical clinic with a hx of a Rt sided breast lump- 5 months duration. Lump was painless, roughly the size of a small lime fruit. No associated skin changes nor nipple discharge, no antecedent trauma, was not breastfeeding prior to the development of lump. No hx of lump in either axilla or other breast, no family hx of breast masses, attained menarche at 13 yrs. LMP. 21/12/05. Breastfed each of her two kids for 13 months.
No associated hx of cough, dyspnoea nor chest pain; no back pain, abdominal pain nor swelling, positive hx of weight loss. The lump was detected during self examination and she reported this during a routine visit to the RVD clinic. Thus, subsequent referral to our clinic.
PMHx: not contributory PSHx: nil FHx: 3rd in a family of six children – 4 girls, 2 boys. Father is late (ripe old age), mother is alive and well, no family hx of similar problem. SHx: Widow- 3yrs ago husband died following protracted illness UNTH medical ward- confirmed RVD positive too.
Has two kids – a boy and a girl –both alive and well. Takes neither alcohol nor tobacco in any form. ROS: not contributory
O/e at the time of presentation: A young woman not pale, anicteric, afebrile, not dehydrated, no generalized lymphadenopathy – stable vital signs Examination of the breast : Lt breast was normal.
Rt breast revealed a small mass 4cm by 4cm in the upper outer quadrant, non tender, firm but mobile, no associated skin changes nor nodal enlargement. Other systems were essentially normal including the MSSK Δsis: .Fibroadenosis initially made but histology report of the excision biopsy confirmed an intraductal Ca of the Rt breast.
Plan: The following investigations were carried out: FBC, S/e/u/Cr CXray – PA, lat Abdominal USS 2 D-Echo a previous CD4 count at the RVD clinic- 340 cells/microlitre.
Histology report of the excision biopsy done revealed an Intraductal CA of the Rt breast. Other results were within normal limit ( wbc – 2,500 cells). Patient was booked for surgery but owing to financial constraints, surgery was delayed, finally carried out 14/3/06 i.e. 6 wks after presentation. A simple mastectomy of the Rt breast was performed.
Post op: received IV ciprofloxacin, metronidazole and IM pethidine for 24hrs, subsequently converted to oral drugs including her anti retroviral drugs and high dose haematinics excluding folic acid containing ones as post op Hb was 7.4gm/dl; evaluation of breast tissue mass for Er/Pr status was requested. Marked clinical improvement. Sutures were removed 10th DPO, patient was discharged to the RVD clinic to see us in two wks time at our Oncology clinic for
commencement of adriamycin-based chemotherapy alongside antiretroviral therapy.
