A 28-year-old white man was admitted to our hospital because of chronic swelling and redness of the left sub-axillary area. No fever, pruritus, or sweating was reported. His past medical history was unremarkable. The patient reported that, after switching deodorant, he noticed a painful swelling in his left axilla 3 months prior to his admission to our hospital. He was treated by his family physician for postulated hidradenitis suppurativa with antibiotics and anti-inflammatory medications, which did not lead to any improvement. Because of the persistence of the lesion in the axilla, a fine needle aspiration was performed then, which showed "atypical degenerating cells suspicious for malignancy". This finding prompted referral to a major tertiary medical center. At that time there was a flare-up of symptoms in the left axilla in addition to the appearance of a new palpable, tender mass in his left supraclavicular area. This mass was chosen by the attending surgeon to be removed for testing. Culture of a part of the removed specimen grew Propionibacterium acnes. Microscopic examination showed fibrous adipose tissue with acute and chronic inflammation findings consistent with organizing abscess. No lymph node tissue was identifiable. Based on these findings the patient received treatment with levofloxacine 500 mg once a day and metronidazole 500 mg three times a day p.o., which, again, did not lead to any improvement.

Physical examination on admission showed temperature 37,5 degrees C and pulse rate 80/min. His body mass index (BMI) was 35,46 kg/m2 (weight: 128 kg, height: 190 cm). He had gynecomastia and inversion of the nipples. Examination of the chest and neck revealed inflammation of the skin surrounding the left nipple, extending up to the left axilla, and a scar in the left supraclavicular area related to previous biopsy (Figures 1-2). Small, palpable, and tender lymph nodes in the left axilla, left and right cervical areas and left and right inguinal areas were also found. All other systems were examined and found normal.

C-reactive protein level was increased at 2.99 mg/dl (normal less than 0.5 mg/dl). Erythrocyte sedimentation was increased as well at 39 mm/first hr. Complete blood count, blood glucose, aspartate aminotransferase (AST), alanine aminotransferase (ALT), glutamyl transpeptidase, bilirubin, lactate dehydrogenase (LDH), creatine phosphokinase (CPK), serum sodium, potassium, urea, and uric acid were all normal. Tests for cytomegalovirus (CMV), Epstein-Barr (EBV) and human immunodeficiency virus (HIV) were negative. Mantoux test was also negative.

Click here for the diagnosis