Oct-Dec 2005: Infections

LymphLink Question Corner - Archived from Oct-Dec 2005
Kathleen D. Francis, MD

Q:  I had a lumpectomy for breast cancer 8 months ago followed by chemotherapy and radiation. Recently I developed redness, soreness and swelling of the breast, but otherwise have been feeling well. Is this an infection?

A:  There are several diagnostic considerations in evaluating someone with the symptoms you describe. The main things that need to be ruled out include infection, inflammatory reaction to surgery and radiation, or a form of breast cancer called inflammatory breast carcinoma.

In persons who have had surgery and irradiation to the breast, lymphatic pathways in the breast presumably have been damaged or impaired. This can result in inefficient drainage of fluid and proteins from the breast, and also decreases the body's immune response in that area. Both of these processes lead to an increased risk of infection, or cellulitis, of the breast.

Cellulitis is an acute inflammation of skin and subcutaneous fat often associated with fever and other systemic symptoms such as tiredness and nausea. The infective organism in the vast majority of cases is presumed to be non-group A streptococcus, but in more than 80% of cases, no bacterial pathogen is ever isolated in the tissue or blood cultures. Infective cellulitis usually responds rapidly to a penicillin or erythromycin, although other antibiotics also may be effective.

In one study, the most important risk factor for the development of breast cellulitis was lymphedema of the breast. Other factors included seroma aspiration or drainage of a hematoma following breast surgery, and a larger volume of breast tissue removed in a lumpectomy.

Cellulitis can also occur in persons who do not have lymphedema or any risk of lymphedema. However, inflammatory and systemic symptoms in persons with lymphedema who develop cellulitis may take longer to resolve than in persons who do not have lymphedema. It is postulated that in persons with lymphedema or who are at risk for lymphedema, the toxins released by bacteria that have been killed by antibiotics or immune responses are not removed efficiently and these toxins set up a persistent local inflammatory response. This may also explain why the bacterial pathogen is infrequently isolated from patients with cellulitis-it may be the inflammatory response to the bacterial toxins rather than proliferation of the bacteria itself that is causing most of the symptoms.

Another consideration in evaluating redness, soreness, and edema of the breast occurring after treatment for the breast cancer is what may be described as non-infective inflammation. In these cases, the symptoms are similar to cellulitis, but are not accompanied by fever or systemic complaints and the onset of the symptoms is often more gradual. For instance, an inflammatory reaction can occur following radiation to the breast and may last for many months. One study referred to an entity called "delayed breast cellulitis" (using the term to mean inflammation rather than infection) in which pain, redness, and skin edema of the breast occurred between 4-15 months after lumpectomy without systemic symptoms, with negative tissue and blood cultures, and with negative biopsies for recurrent cancer. The majority of patients recovered without antibiotic treatment, but the mean time to resolution of symptoms was 7 months.

Because it can be very difficult to distinguish acute infection from the inflammation, the term acute inflammatory episode (AIE) is becoming more common to describe these episodes.

Lastly, breast inflammation and edema that is unresponsive to antibiotic therapy raises the possibility of inflammatory breast cancer, a diffuse neoplastic process that involves the skin lymphatics. Since mammography can be difficult to interpret in this situation, patients may require fine needle aspiration or core biopsy to rule out cancer.

As you can see, evaluation of the symptoms you describe can be a complicated process. In any case of new onset breast redness, soreness and edema, it is important to have medical evaluation to arrive at a proper diagnosis and institute appropriate treatment when needed.

Q:  I have primary lymphedema of my left leg and had one episode of cellulitis in my leg about 7 years ago. I have to undergo dental treatment soon and have heard that I will need to take antibiotics before the procedure to avoid getting an infection. Is this true?

A:  The answer to your question is not a simple one, unfortunately. The question of antimicrobial prophylaxis has been a controversial one for years and recommendations are still evolving. Although prophylaxis in certain groups has become generally accepted, not all applications have been proven. I will quote from an excellent review article on antibiotic prophylaxis in dentistry by Tong and Rothwell in the journal of the American Dental Association in 2000:

"There is a long held belief in the theory of focal infection such that subclinical infectious foci in the oral region .result in systemic illness or cause disease processes in distant locations. Although generally regarded as not having scientific merit, this concept often drives recommendations for the use antibiotics prophylaxis. As a result, dentists and physicians tend to use antibiotics in situations in which there are no clear scientific bases."

One group for whom antibiotic prophylaxis is very well documented in the literature is persons at risk for infective endocarditis (IE), an infection of the lining of the heart or heart valves that can be life-threatening. Those at highest risk for endocarditis include persons with prosthetic cardiac valves, previous endocarditis, severe congenital heart disease, some heart valve disorders, or certain types of pulmonary or ventricular shunts.

Those dental procedures that appear to carry the highest risk for susceptible patients include dental extraction, periodontal procedures such as surgery or scaling, certain endodontic surgery, dental implants and reimplantation, initial placement of orthodontic bands, interligamentary local anesthetic injections, and prophylactic cleaning with anticipated bleeding.

The trend over recent years has been to recommend antibiotic prophylaxis in dentistry for fewer conditions. The American Academy of Orthopedic Surgeons now recommends against routine antibiotic prophylaxis in patients with prosthetic joint replacements. This arose, in part, from studies showing that the risk of death from severe reactions to antibiotics actually far outweighed the risk of late prosthetic joint infection.

In returning to your specific question, the answer at this time is that there is no specific scientifically supported recommendation for antibiotic prophylaxis for dental procedures in patients with lymphedema, all of whom have some risk of cellulitis in the affected limb due to a compromised lymphatic system. Bear in mind that some reactions to antibiotics can be fatal, whereas cellulitis is almost never life-threatening.

The bottom line is that without good scientific studies examining the question of prophylaxis and lymphedema, individuals with lymphedema planning to undergo dental work should be evaluated carefully by a physician to determine the relative risks and benefits of antibiotic prophylaxis in each particular case. My bias is to use antibiotic prophylaxis only for those high-risk dental procedures described above in a few patients who continue to have multiple recurrent episodes of severe cellulitis in the lymphedematous limb or those who have developed cellulitis following a dental procedure in the past. However, different physicians have different approaches to this, and you need to speak with your own physician and dentist who have insight into your particular medical history.

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