E-ISSN:2456-3110

Case Report

Granulomatous lobular mastitis

Journal of Ayurveda and Integrated Medical Sciences

2023 Volume 8 Number 1 January
Publisherwww.maharshicharaka.in

Granulomatous Lobular Mastitis - Ayurvedic understanding and management - A Case Report

Prajitha P.1*, Nikhila K.2
DOI:

1* P.K. Prajitha, PhD Scholar, Department of Prasutitantra & Streeroga, All India Institute of Ayurveda, New Delhi, India.

2 K.P. Nikhila, Assistant Professor, Department of Dravyaguna Vigyan, MVR Ayurveda Medical College, Parassinikkadavu, Kannur, Kerala, India.

Granulomatous lobular mastitis (GLM) is a type of rare benign inflammatory disorder of breast with unknown aetiology. GLM cases presents with breast mass, abscess, inflammation and recurrent mammary duct fistula and necessitates histopathology for an accurate diagnosis. Management of GLM consists of surgical, medical or combined treatment but often results in recurrence, poor wound healing & chronic sinus formation. As per Ayurvedic literature, clinical features of GLM can be considered to different stages of Stana Vidradhi (breast abscess). There are very few reported Ayurveda case studies available in indexed journals in management of GLM. In the present case report a 23-year-old uniparous woman diagnosed with GLM presented with recurrent breast abscess and multiple sinuses over right breast. She was not responsive to steroidal treatment, and required recurrent abscess drainage and sinus tract removal. The condition with presentation of different stages of Sopha (inflammation), Vidhradi (abscess) & Nadi Vrana (sinus), was treated simultaneously with Sophahara and Vranahara medicines internally as well as Kshalana Ropana medicines externally. Multiple hard lumps were treated with application of Sopha-Granthihara medicines. Symptoms completely resolved in 3 months and she was followed-up without medicines for another 2 years during which period no recurrence was observed. Managing such incurable, highly recurrent conditions with Ayurvedic medicines proves to be promising.

Keywords: Granulomatous lobular mastitis, Stana Vidradhi, Sopha

Corresponding Author How to Cite this Article To Browse
P.K. Prajitha, PhD Scholar, Department of Prasutitantra & Streeroga, All India Institute of Ayurveda, New Delhi, , India.
Email: 		P.K. Prajitha, K.P. Nikhila, Granulomatous Lobular Mastitis - Ayurvedic understanding and management - A Case Report. J Ayu Int Med Sci. 2023;8(1):175-181.
Available From
https://jaims.in/jaims/article/view/2154

Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2022-11-29 2022-12-01 2022-12-08 2022-12-15 2022-12-22
Conflict of Interest Funding Ethical Approval Plagiarism X-checker Note
Nil Nil Yes 19%

© 2023by P.K. Prajitha, K.P. Nikhilaand Published by Maharshi Charaka Ayurveda Organization. This is an Open Access article licensed under a Creative Commons Attribution 4.0 International License https://creativecommons.org/licenses/by/4.0/ unported [CC BY 4.0].

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Introduction

Granulomatous lobular mastitis (GLM) is a rare inflammatory disease of the breast. It usually affects women of child-bearing age, with the average age being 35 years.[1] GLM closely resembles the duct ectasia/periductal mastitis complex (DE/PDM) and tuberculous mastitis in the clinical manifestations and imaging examination.[2] Sometimes the condition even mimics breast carcinoma. Patients with GLM have a great diversity of symptoms but most commonly present with a breast mass with or without pain and sometimes skin ulcerations and sinus or fistula formation.[3] The pathogenesis of GLM is still unclear. Multiple factors such as hormonal imbalance, autoimmunity, trauma, Corynebacterium infection, alpha-1-antitrypsin deficiency, and smoking have been implicated as causes or triggering factors.[4],[5] As GLM is a disease with varying symptomatology presenting with different stages of abscess and sinus at the same time, the diagnosis is often confusing. Hence Core needle biopsy and histopathology are mandatory for the diagnosis. There is currently no consensus as to the ideal first-line treatment regimen. The main treatment approaches include antibiotics with repeated drainage, wide surgical excision or mastectomy, oral steroids, immunosuppression with methotrexate, and close follow-up.[6] Moreover, before complete remission, many patients undergo multiple surgical procedures and repeated antimicrobial treatment over months or years, suggesting limited effectiveness of these approaches in GLM.[7]

As per Ayurveda, GLM can be considered as varied presentations of Stana Sopha and Stana Vidradhi. In Ayurvedic concepts, Dhamani (channels) located in breast remains constricted in childhood, whereas these are open in women of reproductive age, which allows the spread of Dosa and results in breast diseases.[8] The vitiated Dosa of breast further vitiates the Rakta and Mamsa, thereby producing Stana Vidradhi.[9] Stana Vidhradhi are types of Bahya Vidhradhi (external abscess). All inflammatory conditions like Vidradhi, Nadi Vrana etc. takes its origin from Sopha. Acharya Susruta has classified Sopha based on the stages of suppuration[10] as Ama Sopha (unripe swelling), Pachyamana Sopha (maturing inflammation) and Pakwa Sopha (mature inflammation).

Whenever suppurating inflammatory swellings are mistaken to be unripe or neglected, then there may be involvement of pus into deeper tissues, which thereby tears up the substrata and open up as sinus.[11] Ayurveda has vividly explained various stepwise treatment procedures for Sopha & Vrana Chikitsa (wound management). Acharya Vagbhata advises the treatment of Sopha (inflammation) in the initial stages and that of Vrana (wound/ulcer) after rupture of abscess.[12] Acharya Susruta has mentioned about the 60 Upakrama (procedures) as well as the 7 basic treatment for wound management in the chapter of Ama Pakweshaniyam. These includes the stepwise protocol of Vimplapana (softening), Avasechanam (draining), Upanaha (Poultice application), Patanam (Incission), Sodhanam (Cleansing), Ropanam (Wound Healing) and finally Vaikrutapaham (Anti scar measures).[13] Wound healing occurs after ordered sequence of events involving interactions among multiple cell populations, cellular components, cytokines, growth factors and the extracellular matrix (ECM). Many Ayurvedic preparations are complex mixtures of several plant parts. Possibility of Ayurvedic approaches having multipronged effect needs to be probed.[14] Appropriate management according to the stage of inflammation is the basic rule in management of Stana Vidhradhi. 

Case Report

A 23-year-old uniparous woman belonging to middle class economic status, presented to the OPD on 19/10/2019 with complaints of recurrent breast abscess and multiple sinuses over the right breast. 6months back she noticed development of multiple painful breast lump on her right breast, some of which developed oozing sinus. She consulted Allopathic hospital where she underwent incision and drainage multiple times. She was also treated with antibiotics. But as she noticed recurrence of the symptoms, she consulted at a tertiary care centre. There she underwent USG which suggested Breast abscess in background of duct ectasia. She underwent true cut biopsy, FNAC and the Histopathology report suggested Granulomatous Lobular Mastitis (GLM). She was managed symptomatically along with steroid therapy- T. Prednisolone 10mg TDS and advised incision and drainage (I & D) in case of abscess formation.


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As there was recurrent abscess formation which required frequent I & D that affected her quality of life and because of marked weight gain following steroidal therapy, she approached Ayurvedic management for a permanent relief.

History of Past Illness

  • History of Allergic rhinitis & recurrent tonsilitis
  • History of Breast eczema

Treatment History

  • Surgical excision of Breast lump
  • Frequent Incision & drainage
  • Steroidal therapy - T. Prednisolone 10mg TDS (3 months)

Menstrual History
Cycles                   : Regular

Interval                : 28-30 days

Duration              : 4 days

Amount               : Heavy (4-5 p/day)

Dysmenorrhea  : Absent

Obstetric History

P1 L1 A0 - FTNVD

LCB - 3yrs, Lactation stopped in the last 6 months

Table 1: Breast examination findings at initial visit

R. Breast Quadrants Inspection Palpation
Upper outer Large 4-5cm sized wound in 10-11 o’clock Granular tissue with oozing (healing wound)
Upper inner 2 reddened 0.5-1cm sized area near 3’o clock Local Temperature at 3’o clock- Abscess site G II tenderness at 3’o clock- Abscess site
Lower inner - -
Lower outer Skin scarring at 7 to 8 o’clock Hard lump over previous scar site at 7 to 8 o’clock
R. Axilla   R. Axillary LN- palpable

Table 2: Investigations

Date Investigation Finding
24/08/2019   USG (Rt) Breast Multiple Hypoechoic collection noted from 11-2 o’clock position of 2*2*3cm possibly abscess in background of duct ectasia
24/08/2019 Pus Culture & Sensitivity Pus cells+, sterile, AFB not seen
24/08/2019 FNAC Suppurative lesion with macrophage collection & granular tissue. No atypical cells seen.
2/09/2019 True cut biopsy Breast tissue showing inflammatory infiltration with fibrous and necrotic tissue concentrated over the abscess wall.
10/09/2019 CBNAAT MTB negative
16/09/2019 Histopathology report Granulomatous Lobular Mastitis. Foci of Abscess formation also seen. GMS stain for fungal organisms negative

Table 3: Date wise intervention

Date Complaint Medication Remarks
9/11/2019 4-5 cm sized wound covering 9- 11 o’ clock   New Abscess at 2-3 o’clock Trayanthyadi Kashaya 40ml BD Guggulupanchapala Churna 5gm BD Haridrakhandam 5gm BD Triphala Kwatha - Kshalan Jathyadi Ghrita - L/A  
24/11/2019 2-3 cm sized healing wound at 10 o’ clock   Tender abscess at 2 o’clock   New abscess at 11 o’clock Gugguluthiktakam Kashaya 40ml BD T.Gandhak Rasayana 1BD Punarnavasava 25ml BD Triphala Kwath + Jathyadi Ghrita L/A (wound site) Shatadhouta Ghrita - L/A (new abscess site) Wound at 11 o’clock position healing
2/1/2020   Avipathikara Churna- 20gm empty stomach (5 Vega) Trayanthyadi Kashaya 40ml BD Guggulupanchapala Churna 5gm BD  
Active abscess forming site (6 o’clock) Shatadhouta Ghrita - L/A
Wound+ sinus (2’o clock) Syringing with Sushavi Kwatha- sinus (Calycopteris floribunda)
Wound healed with small scar at 10 ‘oclock 3-4 cm sized hard, non-tender lump (10-11 o’ clock) Nagaradi Lepa Churna + Karutha Vatt Gutika - paste in Tandulodaka - L/A  
20/1/2020   Varunadi Kashaya 40ml BD Guggulupanchapala Churna 5gm BD  
Wound+ sinus (2’o clock) Syringing with Sushavi Kwatha- over sinus (Calycopteris floribunda)
2-3 cm sized Hard lump (10-11 o’ clock) 2- 3 cm sized hard lump at 6 o’ clock Nagaradi Lepa Churna + Karutha Vatt Gutika - paste in Tandulodaka –L/A
10/2/2020   Varunadi Kashaya 40ml BD Haridrakhandam 5gm BD No palpable lump at 10 o’clock No new active inflammatory site
1cm lump at 6 o’clock (marked reduction) Nagaradi Lepa Churna + Karutha Vatu Gutika- paste in Tandulodaka –L/A
Sinus at 2’o clock- minimally active (occasional oozing) Syringing with Sushavi Kwatha- over sinus (Calycopteris floribunda)
10/3/2020   Haridrakhandam 5gm BD No palpable lump or tender areas in any quadrants of B/L Breast.
10/12/2022     Patient was followed-up without medicines for past 2 years during which no recurrence was observed

Personal history

Diet                        : Non veg, increased use of Katu, Amla, Lavana Rasa, daily use of curd & fish

Food habits         : Irregular

Appetite              : Normal

Bowel                   : Regular

Bladder                : Regular


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Sleep                     : Sound

Psychological status: Anxious

General Physical Examination

Built                       : Obese

Ht                           : 158cm

Wt                          : 70 kg

Pulse                     : 78/mt

BP                           : 110/70 mm of Hg

Temp                    : Afebrile

Breast examination

Left breast- No palpable lump or abnormalities detected

Right Breast

Discussion

During the initial visit there was Tridosha involvement with more of Kapha- Pitta predominance. Simultaneous presentation of different stages of Sopha- Ama, Pachyamana and Pakwa along with Nadi Vrana and Sudha Vrana (healing wound) was present in the same patient. This made the prognosis Krichra Sadhya. As there were different stages co-existing at the same time, treatment was planned considering the Avastha and Dosa predominance. Initially she was advised with Ama pachana, Sopha Hara and Kledahara medicines like Trayanthyadi Kashaya, Guggulupanchapala Churna. For Vrana Ropana of the already existing wound, Prakshalana and Ropana was advised with Triphala Kwath and Jathyadi Ghrita. Trayanthyadi Kashaya[15] mentioned in Vidhradi Chikitsa is highly effective in inflammatory conditions and Pitta predominant diseases. The key ingredients like Katuki, Nimba etc. are Rechaka and Pitta Kapha Dosha Hara. Guggulu Panchapala Churna[16] mentioned in the context of Bhagandara- Nadi Vrana Chikitsa is Ama Pachana, Sroto Sodhana and Vrana Hara. The drug is proven for its anti-inflammatory, anti-oxidant, anti-microbial and wound healing properties.[17] Triphala by its Kashaya Rasa and Kapha Pitta Hara property is Kleda Hara and Vrana Kshalana Ropana thereby helps healing of Vrana faster. Kumar MS et al. stated that Alcoholic extract of Triphala has shown in vitro antimicrobial activity against wound

pathogens. The antibacterial, wound healing, and antioxidant activities of Triphala, was found effective in management of infected wounds.[18] Jathyadi Ghrita[19] mentioned in the context of Vrana Chikitsa in Ashtanga Hridaya is a polyherbal medicine with constituent drugs mainly of Tikta Rasa, Katu Vipaka, Laghu Ruksha Guna and Ushna Veerya. It is more of Vrana sodhana and avasadana thereby promoting the healing of dushta vrana. A study showed that Jatyadi Ghrita significantly helped in reduction of the signs and symptoms of the Dushta Vrana, enhancing wound healing process and reducing the morbidity of the patients.[20]

Further, in order to prevent the development of newer abscess and sinus, medicines that act on deeper Dhatu were chosen. For this Gugguluthiktaka Kashaya and Gandak Rasayana was advised along with syringing of the sinus with Sushavi Kwatha. Gugguglutiktaka Kashaya[21], also known as Pancatiktaguggulu Yoga, is an Ayurvedic formulation useful in chronic inflammatory conditions. Clinical trials have shown that Gugguglutiktaka Ghrita reduces pain, swelling, tenderness in joint disorders.[22] A study states that Gugguluthiktaka Ghrita exerts its anti-inflammatory property by inhibiting the pro-inflammatory cytokine production and the lipoxygenase enzymatic pathway. The study showed that it is more efficient in inhibiting IL-1b, which in turn maybe responsible in controlling various immunological conditions.[23] Gandak Rasayana is a sulphur- based formulation from Rasaratna Samuchaya used effectively in healing of abscesses and chronic non healing wounds. Shetty et al states the possible mechanism of Gandhaka Rasayana by fibroblast activation and by modulation of the proteins involved in tissue remodelling thereby promoting wound healing.[14] Sushavi or Toyavalli- Calycopteris floribunda (Roxb.) Lam is an Ayurvedic drug with healing and anti- ulcer properties. Sushavi is one of the major ingredients of medicines like Krimi Sodhini Vati. Syrininging of the Kwatha in sinus tract showed quick healing and non-progress to wound. Studies prove the antimicrobial and anti- oxidant properties and potent ulcer healing properties.[24] Shata Dhouta Grita [25] application was suggested on the newer inflammatory site to prevent the progress to abscess. Shata Dhouta Grita (clarified butter washed with cold water for 100 times) is one important formulation emphasized in Ayurveda for external application


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in conditions like Daha, Sopha and Visarpa and has proven results in wound healing.[26] Haridrakhandam[27] is an Ayurvedic granule preparation useful in allergic manifestations and as an immune booster. The derangement of immune signals at any stage can result in impaired wound healing. Neutrophils are the first cells to migrate to the wound bed, brought in by pro-inflammatory signals including IL-8. Their apoptosis and engulfment by macrophages (efferocytosis) provides a key signal to the local immune milieu, including macrophages, to transition to an anti-inflammatory, pro-repair state, where angiogenesis occurs and granulation tissue is laid down.[7]

Once complete wound healing was attained and there was no notable recurrence of abscess, the Dosa involvement was reassessed. There was subsidence of Pitta-Rakta Dosa and presence of hard fibrosed lump in the breast tissue indicated Kapha- Medo predominance. Hence the patient was advised with Varunadi Kwatha internally and Lepana over breast lump with Nagaradi Churna and Karuthavattu Gulika. Varunadi Kwatha[28] has Chedana, Lekhana, Kapha Hara and Antar Vidradhi Hara property. Nagaradi Churna[29] and Karutha Gulika[30] or Shirasthoda Gulika are both Lepa Yogas from Sahasrayoga with Ruksha Usna Kapha Hara ingredients which has Lekhana Chedana Sopha-Granthi Hara property. The breast lump got completely resolved and there was no recurrence. After completion of treatment, she was advised to start application of Shata Dhouta Grita if any new inflammatory site developed and to continue internal administration of Haridrakhandam for 1 more month. Patient was under follow up for a period of 2 years during which no recurrence was noted.

Conclusion

GLM is a highly troublesome condition with no standard treatment. Conventional medicine approaches are mainly surgical, steroidal, combined and sometimes observational management is practiced with more of recurrence rate. Treatment with corticosteroid and immunosuppressants often gives symptomatic relief but lifelong medication concerns are high. Ayurvedic Sopha-vrana hara protocols and medicines are highly promising not only in complete cure of GLM, but also in prevention of recurrence and improving the quality of life.

Such findings necessitate the need of further discussions and development of new strategies and protocol in larger sample size for management of rare conditions of breast like GLM.

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