Mammogram for breast pain reveals calcification

Casestudy: A patient with breast discomfort received strange mammography results. Dr Keith Barnard explains.

Abeo joined my list soon after she moved from London. She was Nigerian, had a bubbly personality, and was, shall we say, well endowed.

She had an unpronounceable surname, and insisted I call her by her first name, Abeo. She took great pleasure in telling me it meant 'glad she was born'. She had moved to the UK a few years ago with her husband, an Englishman she had met while he was working in the oil industry in Lagos.

She came to see me because she was having problems with her breasts.

They were becoming lumpy and occasionally tender, and she was concerned because she had not had this problem since she was a teenager, when she suffered a period of considerable discomfort and inflammation that had lasted a year or more.

The symptoms were not consistent, but the variability did not seem to fit a cyclical pattern. However she was now 46, and her periods had been becoming irregular.

It seemed almost certain that this was simply hormonal, but on examination it was impossible for me to determine whether anything more sinister was going on. I thought it best to refer her for mammography, just in case.

The radiologist told me that there were some strange calcifications on the mammograms, and proceeded to ask me about Abeo's history. She concluded by saying she would be discussing the case with her colleagues, and would send me a full report later.

INFESTATION
When the report came back, it was lengthy and interesting, but at least Abeo's life was not in danger. The report described some coil-shaped areas of calcification which the radiologist admitted she had never seen before in the subcutaneous tissue of Abeo's breasts.

However, a little research had revealed that these were typical of the calcified bodies of long-dead guinea-worms, or Dracunculus medinensis. The life cycle of the worm makes uncomfortable reading.

The larvae live in fresh-water fleas that are swallowed by the host. In the stomach the flea is digested, but the worm survives and penetrates into the body. After about a year of growth, the worm migrates to the surface where it appears as a blister-like swelling under the skin. Eventually, the female adult worm bursts out and releases millions of immature larvae into the local river or lake when the host goes for a paddle.

Breast infestation with D medinensis is unusual but by no means unknown in areas where it is endemic. The calcification may be in the ducts, interlobular tissues or subcutaneous fat.

Happily for Abeo, she had no need for any treatment for her long-ago infestation, and the tenderness and lumpiness did turn out to be hormonal.

LESSONS LEARNED

  • Be aware of the possibility of unusual pathology in patients who once lived abroad.
  • The chance of seeing guinea-worm infestation is receding rapidly as it is much less common worldwide than 20 years ago.
  • This is due to an intensive worldwide eradication programme, but it still occurs in sub-Saharan Africa, and some areas of India, Pakistan, the Middle East and South Asia.
  • Treatment of acute infestation is usually with thiabendazole or metronidazole.
  • If diagnosed outside an endemic area, cases should be referred to a tropical diseases specialist.

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