P.G. Department of Shalya Tantra NIA, Jaipur

PRESENTED BY

Dr. Alok KumarPh.D. Scholar

P.G. Dept. of Shalya Tantra N.I.A. Jaipur

A. Particulars of the patientA 64 Year old female

came to NIA shalya tantra OPD on 15/09/2015

B. Chief complaintItching with mild

discharge from a eczematous lesion at rt. Nipple and areola --------4 yrs

C. History of present illnessAccording to patient she was asymptomatic before 4

after that she got a minor trauma on her rt. Breast. After some time she suffered from severe itching in her Rt. Nipple and spread into surrounding areolar area. After sever itching some watery some time red discharge comes from that lesion. She also complain of burning sensation after itching and the lesion becomes Red (erythematous). The lesion progreses very slowly in size.The above complain sometime subside spontaneously and aggravate itself but doesn’t resolve completely. She also complain some scaling from the lesion occaisionly.The severity of disease has no relation with the change in weather.

D. Past history

E. Family HistoryNo significant H/O similar complaints in

family

F. Personal historyAddiction- NoBowel habit- regularSocioeconomic status- Lower middle classReligion-Hindu, vegetarian taking spicy foodOccupation- house wifeMarital status-Married she has 8 child 5 male

and 3 female all are live and healthy.Non lactating, menopausal around 4 yrs backH/O excessive bleeding during Menstruation

period 4 yrs back so she got hysterectomy.

General Physical Examination

Built- AveragePallor- -veCyanosis- -veIcterus- -veClubbing- -veB.P- 100/70 mmHgPR- 84/minTemp.- AfebrileR/R- 20/minGait NLymphadenopathy -no palpable lymph nodesTeeth - Yellow dicolouration

Systemic Examination 1. CNS Examination

Consciousness- Fully Conscious

Orientation- Well oriented to T, P, P.

Speech – Normal

Sensory System- WNL

Motor System – WNL

CVS SystemInspection- B/L symmetrical chest wall, No cyanosis, No

pallor, No clubbing

Palpation- No any tenderness

Percussion- Dull note Auscultation- Heart sounds normal, no murmurs.

Respiratory System Inspection- B/L symmetrical chest wall on

respiration, no dilated veins, scar of previous surgery at left breast. An eczematous lesion at nipple and areola at rt. Breast. Rt. Nipple is retracted.

Palpation- no Tenderness Percussion- B/L Resonant Auscultation- B/L air entry equal , no added

sound

GIT systemAbdominal Examination Inspection- Normal movement with

respiration, no dilated veins, scar of previous surgery

Palpation- soft , Liver non-tendor and spleen not palpable, no any lump or lymph node felt on palpation

Percussion- Tympanic sound noted Auscultation- normal bowel sound

Urogenital systemNo relevant complain of this system

No menstruation cycle.

Local ExaminationPosition – Supine/sitting PositionInspection Both the nipples are at same level, scar of previous surgery at

left breast. An eczematous lesion at nipple and areola at rt. Breast. Rt. Nipple is retracted. The lesion has scales and mild erythma. No dialeted veins on breast.

PalpationOn palpation the lesion is non tendor , cold and mild

indurations up-to areola, nipple is retracted, no lump palpated in both the breast. The lesion is free no sign of fixicity. No edema palpated.

No any lymph node palpable in brachial, pectoral sub-scapular, central , apical, supra-clavicular and cervical group on both side

Diffrential diagnosisEczema of nipplePaget’s diseasePsoriasisDrug eruptionIrritant contact dermatitisMammary duct ectasiaTokar cellsCutaneous melanomaNipple duct adenomaBowens disease (SSC)

Provisional DiagnosisPaget’s disease

Itching +ntScaling +ntUnilateral +ntSpread from nipple to areola +ntPatients age >50 yrs +ntNon lactating +ntDestruction of nipple +nt

Investigations

CBC -WNLESR- 05Rbs-93mg%B.Urea-45S.C.-0.6HBsAg, HIV. -veMAMOGRAPHY - AdvisedHISTOPATHOLOGICAL EXAMINATION OF

LESION Advised.

DiagnosisAwaited for report of epidermal smear and

histopathological report.

TreatmentLumpectomy/MastectomyChemotherapyRadiotherapyAdjuvant treatment

Prognosis The presence of three factors for the prognosis has been suggested,

whether there is a palpable mass of the disease, whether lymph nodes are positive and whether there is an underlying malignant cancer. If there is none of these, the five- and 10-year survival is 85% and 80% respectively, with adjuvant chemotherapy even 95% and 90%. If there is a palpable mass, it is 32% and 31% respectively, with adjuvant chemotherapy (40% and 35%).Positive lymph-nodes have been positively associated with a palpable mass and affect the prognosis to be now just 28% survival after 10 years (vs 79% without palpable mass and without affected lymph-nodes).[Involvement of the lymph nodes does not directly cause any harm, but is merely an indicator of systemic spread.Furthermore, patients with an identifiable associated underlying breast tumor have a survival rate of 38-40% at five years and a survival rate of 22-33% at 10 years. The death rate of metastatic breast carcinoma in patients with mammary Paget's disease and underlying cancer is 61.3%, with a 10-year cumulative survival rate of 33%.