Case Report | Open Access

Clinique Saint jea n de Dieu 75007 Paris France

*Corresponding author: Salmon RJ, Clinique Saint jea n de Dieu 75007, Paris, France

Abbreviations: IBR: Implant-Based Breast Reconstruction

Case Report

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Although predominantly safe and uncomplicated, the post operative course of implant-based breast reconstruction (IBR) may be challenging if infection supervenes. It becomes an anatomical, aesthetic and psychological disaster if removal of the implant is required.
Hopefully, if we can say so, there is other causes of fever and pain in the patients operated on for reconstruction by prosthesis.
We report the unusual case of a woman, born in 1944 (77 years of age at presentation) treated for a bilateral breast cancer . A right mastectomy had been undertaken in 2005 for extended intraductal cancer with an immediate IBR.
A contra-lateral, triple-negative malignancy was diagnosed in 2012 and treated with neo-adjuvant chemotherapy (Taxol Carboplatine), followed one month after termination of chemotherapy by a mastectomy with an axillary dissection. No radiotherapy was performed due to an histopathologically-confirmed complete pathological response. A further immediate reconstruction occurred and the post operative follow-up was uneventful. She was followed regularly every 6 months.
In May 2022 ultrasonography demonstrated a local skin recurrence proven by biopsy, which was treated by a wide local excision and implant exchange in june 2022.The initial post operative course was again uneventful and radiotherapy to the left thoracic wall was planned.
Unfortunately, before this was commenced, the patient presented as an emergency with a pyrexia of 39°, chills and severe pain in the left breast. Clinical examination was unremarkable, with neither erythema nor swelling or enlarged axillary node. Ultrasonography demonstrated a small seroma calculated at 5ml which was aspirated and showed no bacterial growth. In the absence of obvious infection of the prosthesis we enquired into other causes of infection, keeping in mind a possible subclinical/indolent infection due to the repeated surgeries.
After extended questioning the patient reported she had recently cleaned the attic of her country house and have sustained a bite on the left shoulder from a spider. Closer examination of her left posterior shoulder revealed 4 small, black crusty lesions, compatible with this spider bite.
The patient was duly treated with wide spectrum antibiotics , anti histaminics and prednisolone and made a rapid recovery within 8 days. Was a loxosceles bite formally diagnosed.
The literature reveals that Loxosceles rufescens bites are resident in attics of old houses and are known to be responsable for pain, fever and eventually local necrosis. The size of this spider is 8-9 mm according to its gender. Brown Loxosceles rufescens have six pairs of eyes: three pairs forming an half circle. When the spider is adult a spot, in violin form, appears on its abdomen. (See picture) It’s French name "recluse brune" arises from its colour that passes from deep yellow to brown and a preference solitude in unfrequented attics or basements [1].

Hopefully our patient didn’t have the evolution of the « stranger things » season 4 actors [2], nor the cases reported during the movie production of the western « rust » when a technician nearly lost his arm, as well as a french farmer, in the east of France more recently [3].
The literature reveals that Loxosceles rufescens (cf picture) are resident in attics of old houses and that their bites are known to be responsable for pain, fever and eventually local necrosis. L. rufescens bites to humans is reported in 38 publications of which only 11 publications refer to 12 verified spider bites (11% of the reported bites) [4]. Acute hemolytic anemia has been reported in children due to the venom [5] J Time to complete healing ranged from 14 days to more than 8 weeks (mean, 4.8 weeks). A marked relationship was found between age, comorbidities, lesion severity and time to complete healing (P < 0.01) [6].

Discussion

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We discuss a case of metastatic carcinoma of nasopharynx who progressed on multiple lines of chemotherapy and then presented in ER with syncopal attacks and bradycardia.
Cardiac and neurological investigations did not reveal an obvious cause for these symptoms. However, radiological evaluation showed compression of left carotid vasculature. Involvement of carotid sinus was thought to be the most likely cause of these symptoms. Multiple episodes of loss of consciousness, bradycardia and cardiac arrest, were managed with medications. They only provided temporary relief. Palliative course of radiotherapy to the affected area was the modality, which made patient’s symptoms, go away permanently.
Toscano, M and colleagues have recently reported a case of H&N cancer with occult primary and similar successful outcome with radiotherapy [5]. However, in our knowledge, metastatic nasopharyngeal carcinoma causing CSS is extremely rare and there are only a handful cases with either proven nasopharyngeal primary or suspected primary nasopharyngeal carcinoma have ever been reported.
Of course, there is no universally accepted effective treatment for such patients. Different treatment modalities investigated previously include vasoconstrictive drugs, cardiac pacemakers etc. generally and radiotherapy and/or surgical resection of the glossopharyngeal nerve more specifically [6].
A literature review using Med line has been published. It included 12 papers with 41 patients reporting CSS symptoms associated with head and neck cancers. The average time to develop syncopal symptoms was 10 months. Fifteen patients developed syncope post treatment as a symptom of recurrent disease [6].
In carotid sinus syndrome, radiotherapy seems effective for head and neck malignancy [3]. There is limited, if any, benefit of electrophysiological intervention. Pharmacological therapy is found to be effective in some but not all patients. Surgical and radio therapeutic treatment of underlying disease have been most effective in controlling symptoms of syncope [6].
Hence, we suggest that when patients with head and neck cancer present with syncopal symptoms, one should have high index of suspicion for this condition. We should investigate such patients keeping in mind the possibility of tumor mass being close to or involving Carotid sinus as the cause. Management should take into account all factors including fitness, prognosis of individual patient and treatment options available. Amongst non-surgical options, local radiotherapy may be given serious consideration as a quick and effective intervention.

Conclusion

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Plastic surgeons involved in Breast reconstruction can face unusual situations without relationship with there surgical procedures, and facing clinical discrepancies should extend their research toward external causes.
Acknowledgement: Acknowledgements to Dr M. Berry for his help in writing the paper.

References

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1. Fred Vargas. (2017) Quand sort la Recluse: Flammarion Eds. [Ref.]
2. Stranger things. Netflix Series. Season 4. [Ref.]
3. Boissiere F, Masson R, Fluieraru S, et al. (2016) Le loxoscelisme cutané, à propos d’une observation exceptionnelle et de 9 cas consécutifs. Ann Chir Plast Esthet. 61(6): 811-819. [PubMed.]
4. Nentwig W, Pantini P, Vetter RS. (2017) Distribution and medical aspects of Loxosceles rufescens, one of the most invasive spiders of the world (Araneae: Sicariidae). Toxicol. 132: 19-28. [PubMed.]
5. McDade J, Aygun B, Ware RE. (2010) Brown recluse spider (Loxosceles reclusa) envenomation leading to acute hemolytic anemia in six adolescents. J Pediatr. 156(1): 155-157. [PubMed.]
6. Dyachenko P, Ziv M, Rozenman D. (2006) Epidemiological and clinical manifestations of patients hospitalized with brown recluse spider bite. Eur Acad Dermatol Venereol. 20(9): 1121-1125. [PubMed.]