Case Presentation: This patient was a 44-year-old female with a past medical history of localized scleroderma (morphea) of the breast diagnosed by punch biopsy. She presented to the emergency department with right upper quadrant pain and nausea. At that time, a CT scan showed a heterogeneous liver without a definitive underlying mass. Her workup revealed drug induced liver injury possibly from a vitamin supplementation containing clinoptilolite zeolite and phosphatyidyl choline by her chiropractor. Although there is no definitive evidence of hepatotoxicity from these agents, they were discontinued. She received supportive care and was discharged with outpatient gastroenterology follow up. On outpatient follow up, her liver function tests were noted to be worsening despite stopping the vitamin. She was then readmitted and had repeat imaging with MRI of the abdomen. It showed severe acute hepatitis without evidence of intra-or-extrahepatic bile duct dilation or solid intrahepatic lesion. There was also a right pleural effusion and incompletely visualized right cutaneous breast thickening with edema. A thoracentesis was performed and revealed an exudative fluid concerning for malignancy. Initially, a source could not be found despite increased CA125 and a negative pelvic ultrasound. Subsequently, the patient’s mental status declined, and she was transferred to the intensive care unit for acute liver failure (ALF). Ultimately, a liver biopsy was done and showed carcinomatous infiltrate of the liver, most likely from primary breast carcinoma. The specimen also stained positively for HER2-neu. The patient’s family decided to change her care to comfort measures only, and she passed away several days later. Of note, this patient had a recent negative mammogram, but a core biopsy was never done.
Discussion: Morphea is an inflammatory disease leading to sclerotic changes in the skin. Although systemic sclerosis (SS) is associated with an increase in malignancy, there is limited data linking morphea with cancer. There have been studies showing a temporal clustering of SS with breast cancer diagnosis. Consequently, the authors recommended that women diagnosed with SS should have annual mammograms starting at age 40. This case report suggests that similar recommendations should be made for patients with morphea of the breast tissue since it could be a precursor to breast cancer. Moreover, this case illustrates the importance of considering malignancy as the cause of ALF in a breast morphea patient. Ultimately, these patients may benefit from an oncological workup while admitted as an inpatient.
Conclusions: Our case report suggests that morphea of the breast tissue could be a precursor to the disease. There is not any published data at present regarding prevalence of breast cancer in patients with morphea, and more studies are needed to establish this relation. Until we have more data, our case report suggests that there might be an association between morphea and breast cancer. Therefore, if a patient with a history of breast morphea presents with ALF, a diagnosis of metastasized breast malignancy should be considered as a cause.