A Silent Killer in an Unlikely Place: Necrotizing Fasciitis of the Breast

Background: Primary necrotizing fasciitis (NF) of the breast is a rare, life-threatening soft tissue infection that is frequently misdiagnosed due to its non-specific early presentation and uncommon anatomical location.Objective: We report a case of primary NF of the breast to highlight the diagnostic challenges posed by atypical risk factors and the critical importance of timely surgical intervention and antibiotic cover.Methods: A 66-year-old female presented with breast pain, erythema, and systemic symptoms in the setting of hidradenitis suppurativa (HS) being treated with adalimumab and long-standing tobacco use. Clinical assessment, laboratory investigations, and computed tomography (CT) imaging were performed, followed by surgical exploration.Results: Initial concerns included abscess formation, cellulitis, or a HS flare. However, clinical instability and CT imaging demonstrated a gas-filled structure in the medial left breast with a developing gas-filled collection. Surgical exploration revealed extensive necrotising fasciitis involving the medial quadrant of the inner breast and underlying fascia, necessitating emergent surgical debridement and broad-spectrum antimicrobial therapy. The patient required further debridement and wound management, followed by delayed reconstruction.Conclusion: This case illustrates how underlying risk factors, particularly immunosuppression, may predispose patients to atypical presentations of NF and reinforces the importance of early surgical and antibiotic intervention when clinical suspicion is high.