Promoting Early Detection of Necrotizing Soft Tissue Infection of the Upper Extremity in Patients with History of Breast Cancer: A Case Report

Abstract Background: Breast cancer survivors are known to be at an increased risk of adverse health events, including lymphedema and skin infections, even decades after their initial diagnosis and treatment. Despite the high prevalence of secondary lymphedema amongst breast cancer survivors, it remains unrecognized and underdiagnosed by patients and physicians alike. Case Presentation: A 56-year-old female with a three-year history of remission of breast cancer, status post bilateral total mastectomy with right axillary node dissection complicated by a seroma of the right chest wall and adjuvant chemotherapy and radiation, presented with a one-week history of worsening right upper extremity erythema, edema, and tenderness. She denied any known trauma, needle insertions, or insect bites. On initial examination, she was afebrile, hypotensive (90/60 mmHg) with an erythematous, edematous right bicep that was tender and fluctuant to palpation. Distal pulses, strength, and sensation were at baseline bilaterally. CT and ultrasound imaging showed extensive subcutaneous edema and skin thickening of the right arm, compatible with cellulitis. The patient was diagnosed with a necrotizing soft tissue infection of the right upper extremity and treated with antibiotic therapy, incision and drainage, controlled surgical debridement, and eventual Polynovo grafting. Conclusions: In one of the first documented cases of necrotizing soft tissue infection in the context of lymphedema, of either primary or secondary etiology, we highlight the need for patient and physician education regarding secondary lymphedema in breast cancer survivors to promote early detection and intervention—a critical first step to prevention of superimposed infectious etiologies.