31 Concerning a case: innovative approach to managing sepsis from an infected breast prosthesis

Abstract We present a 45-year-old patient with right breast neoplasia and BRCA2 genetic mutation. She is discussed in a multidisciplinary breast cancer committee and was considered to be a candidate for bilateral skin and nipple sparing mastectomy with sentinel lymph node biopsy. The surgery was performed endoscopically through lateral incisions of 3.5 cm in the axillary midline. During surgery, the presence of retroareolar tumor cells was found, requiring a new retroareolar resection to ensure the anterior margin and to maintain the nipple-areola complex. The immediate postoperative course was favorable and the patient was discharged after 48 hours. In outpatient follow-ups, drainage is monitored, and necrotic tissue is observed exclusively in the nipple during ambulatory check-ups, with satisfactory progress. At 15 days drainage is removed in the right breast, but the patient reconsults at 48 hours due to pain in the breast, erythema in the drainage orifice and slight increase in volume in the lower outer quadrant and center of the breast. Drainage is performed by puncture and purulent material is analized and the patient is admitted with intravenous antibiotherapy. During 5 days the patient presented progressive worsening with increased erythema, pain, fever and sepsis in analytical (>20 000 leukocytes and CRP >400 mg/l) so it is proposed to explant the prosthesis. The patient refuses to have the prosthesis removed and requests conservative management, refusing the explant even with the vital risk involved. In front of a competent patient, an attempt of ‘prosthesis conservative’ management was decided, performing surgery with intense washing of the mastectomy cavity, Friedrich of necrotic plaque with direct suture and prosthesis placement with previous drainage, washed with betadine, prontosan and antibiotherapy + sensitive antifungals according to initial antibiogram. She was hospitalized for 10 days with antibiotics and endovenous antifungal well tolerated, with progressive improvement and discharge with oral antibiotics and control in external consultations. The patient maintains good evolution with normalization of her septic status and good aesthetic result. The pathological anatomy showed free surgical margins.