lupus mastitis presents as single or multiple subcutaneous or deep breast masses , clinically mimicking malignancy [ figure 1 ] .
lupus mastitis presenting as the initial manifestation of lupus erythematosus ( le ) is very rare .
later , she developed discoid le ( dle ) lesions on breast and other sites without any systemic symptoms of le [ figure 2 ] .
evolution of one connective tissue disease to other remains a perplexing event , though there are reports .
literature search shows only a single case of dle progressing to systemic pan even though many cases of systemic le evolving to systemic pan has been reported .
right breast shows atrophy , discoid lupus erythematosus lesions on surface discoid lupus erythematosus lesion in ear
a 35-year - old female presented with hyperpigmented papules on right breast , face and limbs , and weakness of right little finger of 2 weeks duration .
there was no history of tuberculosis , joint pain , photosensitivity , or raynauds phenomenon .
cutaneous examination revealed multiple hyperpigmented discrete and confluent atrophic plaques with adherent scales over the right breast .
breast tissue also showed induration with multiple discrete nodules of size 1 cm  2 cm .
multiple discrete hyperpigmented scaly papules and plaques were present on the upper arms , face and ear concha ( schuster sign ) [ figures 1 and 2 ] .
we had the differential diagnosis of papulonecrotic tuberculid and disseminated dle ( ddle ) ; for the breast nodules , we considered tuberculous mastitis and lupus mastitis .
renal function test , antinuclear antibody ( ana ) , ana profile , and c3 , c4 levels were normal .
mantoux test , perinuclear anti - neutrophil cytoplasmic antibody , and viral markers were negative .
magnetic resonance imaging aortogram revealed luminal irregularity and beaded appearance of left renal artery near the hilum .
skin biopsy from breast lesion shows atrophy of epidermis , follicular plugging , and basal cell degeneration deep biopsy from breast showed features of dle with mixed panniculitis and lymphocytic vasculitis with mucin deposition in dermis , suggestive of lupus mastitis [ figures 4 and 5 ] .
deeper biopsy from breast tissue shows lymphocytic vasculitis and lymphoid aggregates alcian blue stain shows mucin deposition in dermis usg breast showed ill - defined hypoechoic mass with atrophy of fat and large calcifications in fat and breast tissue [ figure 6 ] .
ultrasound picture of breast shows atrophy of breast tissue , large masses of calcification hence , the final diagnosis was lupus mastitis evolving to ddle and systemic pan .
lupus mastitis affects women with a mean age at diagnosis of 40 years and can occur in males also .
the condition leads to fat necrosis , calcification , fibrosis , scarring , and breast atrophy .
most commonly , lupus mastitis is seen in patients with a previous diagnosis of systemic or discoid lupus .
however , in our patient , lupus mastitis was the initial presentation . in the absence of skin lesions and background of le
, it poses a diagnostic challenge and the differential diagnosis involves carcinoma , tuberculosis , idiopathic granulomatous mastitis , lymphoma , and involvement of breast in medium vessel vasculitis .
traumatic procedures such as biopsy may worsen the condition , and it is advisable to avoid biopsy if the diagnosis can be established with the clinical and radiological features .
fine - needle aspiration cytology shows degenerated fat cells with scattered foci of calcification and lymphocytic predominance .
histological findings in lupus panniculitis are hyaline fat necrosis , lymphocytic infiltration surrounding the necrosis , periseptal or lobular panniculitis , and microcalcifications .
other findings include changes of dle in the overlying skin , lymphocytic vasculitis , mucin deposition , and hyalinization of the subepidermal papillary zones .
typical mammographical appearance include segmental heterogeneous calcifications , some curvilinear and coarse due to fat necrosis .
ultrasound shows an ill - defined , isoechoic , or hyperechoic mass , but our patient had hypoechoic lesion , large calcifications , and lipoatrophy .
she also satisfied the criteria for systemic pan . in 1990 , the american college of rheumatology established criteria for pan .
at least 3 of the 10 criteria should be present : 
 weight loss > 4 kglivedo reticularistesticular painmyalgiamononeuropathy or polyneuropathydiastolic blood pressure > 90 mm / hgelevated blood urea nitrogen or creatinine levelpresence of hepatitis b surface antigenarteriogram demonstrating aneurysmsbiopsy of small- or medium - sized artery containing neutrophils . 
 
mononeuropathy or polyneuropathy diastolic blood pressure > 90 mm / hg elevated blood urea nitrogen or creatinine level presence of hepatitis b surface antigen arteriogram demonstrating aneurysms biopsy of small- or medium - sized artery containing neutrophils .
our patient satisfied this criteria , and literature search showed few reports of systemic lupus erythematosus ( sle ) progressing to pan , but only a single report of dle going for pan . in this case , we faced two questions , is the breast swelling lupus mastitis or pan of breast tissue and whether the patient has a single connective tissue disease or both le and pan .
we report this case as lupus mastitis is a rare entity , and its presence as the initial manifestation of le is still rare .
lupus mastitis presented as initial manifestation of le , so it remained undiagnosed for many years . even though there are reports of sle evolving to pan , a case of dle going to pan is rare .
lupus mastitis presented as initial manifestation of le , so it remained undiagnosed for many years .
even though there are reports of sle evolving to pan , a case of dle going to pan is rare .
lupus mastitis presented as initial manifestation of le , so it remained undiagnosed for many years .
even though there are reports of sle evolving to pan , a case of dle going to pan is rare .
 lupus mastitis is an uncommon presentation of lupus erythematosus profundus ( le profundus ) , characterized by inflammation of the subcutaneous fat . 
 le profundus occurring as initial manifestation of le is rare . 
 we report a case where the patient presented with lupus mastitis and years later , she developed disseminated discoid le ( dle ) and polyarteritis nodosa ( pan ) . 
 pan and dle are connective tissue diseases with different etiologies , clinical , immunological , and histopathological features . 
 one connective tissue disease evolving into another is rare , and the reasons remain unexplained . 
 this woman had histopathologically proven dle and lupus mastitis with a negative antinuclear antibody profile . 
 she satisfied the american college of rheumatology criteria for pan . 
Introduction
Case Report
Discussion
None
Financial support and sponsorship
Conflicts of interest