Multiple nodules of Pseudoangiomatous Stromal Hyperplasia (PASH) in a menacme patient: a case report

Introduction: Pseudoangiomatous Stromal Hyperplasia (PASH) is a rare benign proliferating breast condition. It was first described in 1986 and less than 200 cases have been described ever since in the English literature. In the majority of cases, PASH is an incidental histological finding, but it can also be found in the physical examination as one typical single nodule (palpable, circumscribed, non-hemorrhagic), mostly on pre-menopausal women. It is frequently misdiagnosed as a fibroadenoma. PASH's etiology remains unclear, although it is related to different benign breast entities. Objectives: This report aims to describe a case of multiple PASH nodules in a 31-year-old woman, its diagnosis and management. Case report: VSS, female, 31 years old, previously healthy, presented with increased right breast volume (swelling) for the last six months. She denied local pain and fever at the spot. When examined, right breast was bigger than the left one and showed discrete hyperemia. There were neither palpable nodules on the breasts nor axillary lymph nodes. The attending physician ruled the diagnosis as mastitis and prescribed clyndamicin for 7 days. He also ordered an ultrasound for complementary information. The exam result (ACR BI-RADS: 2) showed swelling, simple cysts (the biggest one measured 1.2 cm) and confirmed the diagnostic hypothesis for the right breast. When the patient returned for another appointment, 2 weeks after the first consultation, there was a palpable, mobile nodule in the lower-outer quadrant of the right breast of approximately 5.0 cm. She also reported pain in the area and denied fever. The attending physician kept with the mastitis diagnosis and prescribed metronidazole and cefalexin for 7 days. The patient was asked for another ultrasound along with a mammography. The patient returned again, 2 weeks after the last (and second) appointment. The mammography showed a nodule, in the lower-outer quadrant of the right breast, measuring 7.5 cm that matched with the pain-sensitive area in the patient breast. There was no sign of calcification and the exam was ruled as ACR BI- RADS: 0. The ultrasound result was still pending and, at that moment, the attending doctor changed the hypothesis to granulomatous mastitis. He prescribed the patient with methotrexate three times a week. He also requested a core-biopsy of the right breast. The patient had a new appointment (fourth) a month after the third consultation: she denied any improvement of the