Pediatric breast abscesses require timely infection control while minimizing injury to the developing breast. We report an 11-year-old pubertal girl with persistent left breast pain, swelling, and erythema after 7 days of oral antibiotic therapy. Physical examination revealed a fluctuant left breast mass and a tender contralateral cystic lesion. Inflammatory markers were elevated. Ultrasonography demonstrated a heterogeneous left-sided collection with peripheral vascularity, consistent with abscess formation, whereas the right breast showed a well-circumscribed anechoic cyst without inflammatory features. The antibiotic-refractory abscess was treated by incision and drainage, and the contralateral cyst was managed by needle aspiration. Culture of the purulent fluid yielded Staphylococcus epidermidis. Two-month ultrasonography showed marked lesion reduction. At 12-month clinical follow-up, no recurrence, nipple discharge, or obvious breast asymmetry was observed. The case shows how ultrasonography helped separate an abscess requiring drainage from a contralateral cyst that could be treated by aspiration.

Adenoid cystic carcinoma (ACC) of the breast is an exceptionally rare malignancy, representing less than 0.1% of all breast cancers. Although it often demonstrates a triple-negative immunophenotype, its clinical course is typically more indolent than conventional triple-negative breast carcinomas. We report the case of a 64-year-old woman who presented with spontaneous nipple discharge from the left breast. Imaging revealed a suspicious lesion (Breast Imaging-Reporting and Data System (BI-RADS 5), leading to a core needle biopsy and tumorectomy, which identified a 2 cm invasive carcinoma of no special type. Completion mastectomy with axillary lymph node dissection revealed an 18 mm residual grade 1 tumor with clear margins and no nodal involvement. Immunohistochemistry confirmed a triple-negative profile, and staging CT scans showed no evidence of distant metastasis. The patient subsequently underwent adjuvant radiotherapy to the left chest wall. Given these findings, including complete surgical resection, absence of nodal involvement, and lack of distant metastasis, the clinical course is consistent with the favorable prognosis typically observed in breast ACC. This case highlights the diagnostic challenges, distinctive pathological features, and favorable outcomes associated with this rare entity, emphasizing the importance of accurate histopathologic evaluation and appropriate surgical management in guiding long-term prognosis.

Invasive Paget's disease of the breast is a rare entity with therapeutic challenges. Herein, we report three patients with Paget's disease of the breast with dermal invasion, of which two cases had coexistent invasive breast carcinoma, while the third had an extensive in situ component. Case 1 was a 49-year-old lady presenting with nipple ulceration and discharge along with concomitant multicentric right breast lesions detected on mammography. Breast conservation surgery was performed which revealed extensive high-grade ductal carcinoma in situ on histopathology, associated with invasive Paget's disease. The patient completed adjuvant radiotherapy and shows no evidence of disease at present, four months following the completion of therapy. Case 2 was a middle-aged woman of 45 years, who was detected with multiple hypoechoic space-occupying lesions in the right breast on ultrasonography. Modified radical mastectomy was performed which showed a tumor-infiltrating lymphocyte-rich breast carcinoma along with invasive Paget's disease. Following surgery, she is currently on adjuvant chemotherapy with no evidence of disease. Case 3 was a 47-year-old lady presenting with a lump in the right breast with nipple ulceration. Microscopic examination of the modified radical mastectomy specimen showed a high-grade invasive breast carcinoma along with invasive mammary Paget's disease. Follow-up imaging showed generalized lymphadenopathy. The patient was advised adjuvant chemotherapy; however, she was lost to follow-up after receiving the first cycle of treatment. We present three cases of invasive Paget's disease of the breast highlighting the importance of recognition of this rare entity with distinct therapeutic implications.

A 66-year-old woman presented with right bloody nipple discharge (BND). Initial evaluation, including palpation, mammography (MMG), ultrasonography (US), and cytology, revealed no abnormalities. In the second year, persistent BND prompted breast magnetic resonance imaging (MRI), which demonstrated non-mass enhancement in the lower right breast and was classified as Breast Imaging Reporting and Data System (BI-RADS) category 3; therefore, imaging surveillance was performed. In the third year, cytological examination revealed atypical cells. Repeat MRI again demonstrated non-mass enhancement. US/MRI fusion identified two suspicious regions; however, ultrasound-guided needle biopsy showed no evidence of malignancy. Because of persistent BND and cytological atypia, excisional biopsy was performed, and ductal carcinoma in situ (DCIS) was confirmed. US/MRI fusion may assist in localizing target areas for biopsy in patients with MRI-detected lesions without corresponding findings on MMG or US; however, histopathological confirmation remains essential.

Granulomatosis with polyangiitis (GPA) is a rare ANCA-associated small-vessel vasculitis that predominantly affects the respiratory tract and kidneys, while cutaneous manifestations occur less frequently. Opportunistic fungal infections complicating GPA are uncommon, particularly involving rare filamentous basidiomycetes. We describe a 32-year-old male with a prolonged history of crusting rhinitis, tinnitus, and progressive nodular and ulcerative skin lesions on the trunk and extremities, accompanied by fever and lower limb edema. Laboratory evaluation revealed elevated inflammatory markers and positive c-ANCA (anti-PR3). Histopathology demonstrated granulomatous inflammation consistent with GPA. The clinical course was complicated by a secondary cutaneous infection caused by Hormographiella aspergillata, isolated from a skin lesion. Initial antifungal therapy with itraconazole was ineffective; subsequent treatment with voriconazole resulted in resolution of the fungal infection. The patient was then successfully treated with systemic immunosuppressive therapy, achieving long-term remission. To our knowledge, this is the first reported case of GPA complicated by a cutaneous infection with H. aspergillata. This case highlights the diagnostic challenges of GPA with atypical skin manifestations and underscores the importance of microbiological evaluation of skin lesions prior to initiating aggressive immunosuppressive therapy. KEYWORDS: granulomatosis with polyangiitis; ANCA-associated vasculitis; Hormographiella aspergillata; opportunistic fungal infection Granulomatosis with polyangiitis (GPA), formerly Wegener's granulomatosis, is a necrotizing granulomatous vasculitis affecting small to medium-sized blood vessels and belonging to the group of ANCA-associated vasculitides (AAV) (1). The disease is characterized by granulomatous inflammation, necrotizing vasculitis, and the presence of antineutrophil cytoplasmic antibodies, most commonly proteinase-3 ANCA (PR3-ANCA) (2). GPA may involve virtually any organ system, with predominant involvement of the upper and lower respiratory tract and kidneys (3). Cutaneous manifestations are reported in approximately 30-50% of patients and are usually associated with systemic disease activity (4). Opportunistic infections may complicate the course of GPA, particularly in the context of delayed diagnosis or immunosuppressive therapy. Infections caused by rare filamentous fungi such as Hormographiella (H) aspergillata are exceptionally rare and have predominantly been reported in immunocompromised patients with hematological malignancies (5, 6). A 32-year-old male was admitted with multiple painful ulcerations and nodules on the trunk and extremities, accompanied by high fever and marked bilateral lower limb edema. Four months before admission, nodular lesions on the left auricle and right nipple regressed spontaneously after purulent discharge. Six weeks prior to referral, painless nodules on the back and right upper arm were surgically incised and treated with antibiotics, followed by clinical deterioration with fever, progressive ulcerations, and painful swelling of the feet and ankles (figures 1a and !b). The patient had a two-year history of nasal obstruction, crusting rhinitis, and intermittent right-sided tinnitus. Rhinoscopy revealed mucosal thickening and septal perforation with crusts and synechiae. Dermatological examination showed deep ulcerations with yellow-brown crusts on the back, right upper arm, and left cheek (figures 1a and 1b). Laboratory evaluation demonstrated elevated inflammatory markers (ESR 76 mm/h, CRP 47.4 mg/L), hypoalbuminemia, and positive c-ANCA (anti-PR3). Initial microbiological cultures were sterile. Histopathology revealed granulomatous panniculitis with abscess formation. Fungal culture isolated H. aspergillata. Itraconazole therapy was ineffective; subsequent voriconazole treatment led to complete resolution of the cutaneous infection. Due to persistent systemic inflammation and c-ANCA positivity, the patient was treated with high-dose glucocorticoids and cyclophosphamide, which gradually led to completely remission of skin lesions (figure 2). Renal involvement developed during treatment, manifested as proteinuria. Long-term immunosuppressive therapy resulted in sustained remission with mild residual renal impairment. GPA is a rare multisystem autoimmune disease with heterogeneous clinical presentation, often leading to delayed diagnosis. Cutaneous involvement may be the initial manifestation and includes purpura, nodules, necrosis, and ulcerations, reflecting underlying vasculitis and granulomatous processes (2). In our patient, prominent skin lesions preceded the diagnosis by several months and contributed to diagnostic uncertainty. Opportunistic infections are a recognized complication in GPA, particularly following immunosuppression; however, fungal infections caused by filamentous basidiomycetes are exceedingly rare (5, 6). Hormographiella aspergillata, the anamorphic form of Coprinopsis cinerea, is an environmental fungus that has been implicated almost exclusively in invasive infections in patients with hematological malignancies, with reported mortality rates up to 70% (5, 6). To our knowledge, no previous case of GPA complicated by cutaneous infection with H. aspergillata has been reported. The present case underscores the importance of thorough microbiological evaluation of atypical or non-healing skin lesions in patients with suspected systemic vasculitis, particularly before initiation of intensive immunosuppressive therapy. Failure to recognize opportunistic infections may lead to significant morbidity and mortality. This case emphasizes the crucial role of dermatologists in the early recognition of systemic vasculitis presenting with skin manifestations. Comprehensive clinical, histological, and microbiological assessment is essential to establish the correct diagnosis and to identify rare infectious complications. Multidisciplinary management and careful monitoring are necessary to achieve long-term remission and to minimize treatment-related complications.