Presentations

Abstract

Introduction:

This project is identifying hidradenitis suppurativa (HS) in MRI imaging, and how to stage it properly. HS is a chronic, recurrent, painful inflammatory skin disease of the skin. The inflammation is caused by hair follicle blockage, that causes dilation and rupture, followed by an inflammatory process that can lead to abscess formation and destruction of the surrounding area. This inflammatory process can lead to chronic recurrent infection, scarring, and sinus tract formation. The areas that are typically affected are intertriginous areas of the body, such as the axilla and inguinal region. Here, we present a case of a 45 year old woman who received breast imaging in multiple modalities, after which she had an abscess drainage. Ultimately, she was diagnosed with bilateral HS.

Case Information:

This patient presented with bilateral breast redness and swelling over several months. She had a mammogram which revealed bilateral masses, highly suggestive of malignancy. MRI of the breast showed bilateral, multiloculated masses suggestive of an inflammatory process, but was not able to rule out malignancy. The patient had three breast procedures and an incision and drainage (I&D) which revealed bilateral, multifocal breast abscesses with sinus tracts. Despite multiple courses of antibiotics, her pain did not subside. The patient had three breast procedures and an I&D revealed bilateral, multifocal breast abscesses with sinus tracts, leading to the diagnosis of HS. The lack of sinus tract formation on initial breast imaging and the location of her abscesses necessitated the patient to have multiple imaging studies.

Discussion:

HS is a chronic, recurrent, painful inflammatory disease of the skin. HS has an overall prevalence range of 0.1-2%. Risk factors for HS include African American race, obesity, and lower socioeconomic status. Imaging for HS can be done with ultrasound or MRI. MRI can be used to properly stage HS and characterize the lesion, leading to the proper treatment. Staging of HS can be done using the Hurley Criteria. For example, initial MRI findings will show dermal thickening and subdermal induration, which appear as high signal intensity on T2-weighted imaging; staging depends on the image findings. Treatment for HS includes topical medications, systemic antibiotics, and wide excision of the lesions. If HS is not properly controlled, there is a small but notable risk of converting to squamous cell carcinoma. The patient in this case had an MRI with findings of bilateral abscesses, though HS was not diagnosed with this imaging. The lack of sinus tract formation and the atypical location of the breast abscesses made a radiologic diagnosis of HS difficult. Including contrast in the imaging protocols may have led to a faster diagnosis of HS, allowing proper staging.

Conclusion:

This case reveals that HS should be on the differential when there is suspicion of a bilateral breast inflammatory process that may be abscesses. HS can be properly seen and staged with MRI. However, due to the atypical location of the HS associated abscesses in this patient's case, there was a concern for malignancy and HS was not initially diagnosed. The sinus tracts were not well visualized in imaging because of the patient's dense breast tissue, and lack of contrast. This case highlights the importance of adding intravenous contrast in the breast MRI protocol, and the fact that HS can be found in unusual places such as the breast.