Breast cancer survivorship complicated by fatal lymphedema-associated necrotizing soft tissue infection

What happened, in summary

This 56-year-old woman was a former smoker with a history of ER-positive, PR-positive, HER2-negative invasive ductal carcinoma of the right breast. Five years earlier, she had undergone bilateral total mastectomy with right axillary node dissection, followed by adjuvant anthracycline- and taxane-based chemotherapy and radiation. That breast cancer treatment was complicated by right axillary hematoma and chest wall seroma. She later came to the hospital with 1 week of worsening redness, swelling, tenderness, and pitting edema in the right upper arm. Examination showed a tender fluctuant papule on the right bicep, hypotension, tachycardia, and swelling that did not improve with elevation, consistent with stage II secondary lymphedema. Laboratory tests showed marked leukocytosis and inflammation, elevated blood urea nitrogen and creatinine, and CT imaging showed extensive subcutaneous edema and a phlegmon compatible with severe soft-tissue infection. She was admitted to the ICU with septic shock, and distal pulses, strength, and sensation were preserved at baseline during the early evaluation. Initial incision and drainage released purulent fluid, and bedside wound checks found extensive fat necrosis with heavy bacterial growth, including Streptococcus pyogenes and methicillin-resistant Staphylococcus aureus. Operative debridement removed devitalized tissue down to the bone, and pathology confirmed necrotizing soft tissue infection with abscess and thrombosis. She received antibiotics, repeat debridement, drainage, negative-pressure wound therapy, synthetic dermal grafting, and placental-based allografting. Her condition improved enough for transfer out of the ICU for wound care and physical therapy. Four weeks later, while awaiting rehabilitation placement, she developed hospital-acquired pneumonia, acute respiratory failure, and profound acidosis. Despite intubation, she died shortly afterward.