Asymmetric breast enlargement minus central venous thrombosis in a hemodialysis patient

A 76-year-old woman hemodialysis patient was hospitalized for community-acquired pneumonia complicating chronic obstructive pulmonary disease. End-stage renal disease secondary to hypertension had been diagnosed at the age of 64 for which the patient was initiated on maintenance hemodialysis. Then, she received a deceased donor kidney transplant at the age of 68 that succumbed to chronic rejection 4 years later when she was restarted on hemodialysis. Hemodialysis was performed via a right subclavian vein double lumen catheter for 2 months when a right brachio-axillary graft was inserted. Severe venous congestion, swelling, and nipple tenderness of her right breast noted on admission had been increasing for 6 weeks before hospital admission. No arm swelling was evident. Initial management of the patient's pneumonia and chronic obstructive pulmonary disease consisted of intravenous ceftriaxone and albuterol inhaler to which intravenous oxacillin (1 g q 6 hr) was added for presumed right mastitis. Radiological work-up for masses and malignancies was negative. An angiogram of the right upper extremity detected stenosis of the dialysis access graft at its anastomosis with the axillary vein. Angioplasty of the stenosis was performed without incident or evidence of central vein stenosis. Rapid resolution over 10 days of the unilateral breast congestion followed without complication.