Intense Hoe-Farming: an Unusual Cause of Mondor’s Disease in a Rural Tanzanian Farmer
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Mondor’s disease is a rare self-limiting condition which presents with a palpable cord-like enlargement of superficial veins of the breast and anterior chest wall and sometimes the arm or penis. Reviews indicate that a number of cases have been reported in western countries. In Tanzanian literature, no case has been documented to the best of my knowledge.
A 52-year-old Tanzanian woman residing in a rural area whose main occupation is a physically exerting hoe-farming. She reports insidious appearance of subcutaneous cord-like band which was initially painful and subsequently became painless and associated with tension and skin retraction. The band extended from below the left breast on the thorax to the upper abdominal wall. Reassurance, rest from farming activity and 2-week course of indomethacin tablets resulted in complete relief.
A rural farmer with thrombophlebitis of superficial vein below the breast was reported. Along with the discussion of the relevant literature is the acknowledgment that physical exertion of the chest wall from prolonged forceful farming activities may predispose individuals to Mondor’s disease.
KeywordsCase report Rare Mondor Tanzania Rural Farming
Mondor’s disease draws its name from a French surgeon, Henri Mondor, who first described the disease in 1939 in reference to thrombophlebitis on the superficial thoracoabdominal wall . The condition is rare, benign and self-limiting in nature [1, 2, 3]. The disease involves insidious appearance of subcutaneous cord-like band associated with tension and skin retraction [4, 5]. The commonly affected areas are the penis (subcutaneous penile vein thrombosis), anterior chest wall, abdominal wall, arm and axilla [4, 5].
Symptoms include insidious appearance of a subcutaneous cord-like band or lump which may be initially red and tender and subsequently becomes painless, tough and fibrous accompanied by tension and skin retraction on the anterior chest wall or breast [1, 2, 3]. Literature further suggests that the enraged superficial vein often takes a longitudinal shape on the anterolateral area of the thoracic and abdominal wall .
The causes of Mondor’s disease are mainly unknown with some literature describing the condition in relation to iatrogenic causes such surgical operation, radiation, hormonal therapy and trauma [1, 2, 3]. Some literature indicate that the thrombophlebitis of superficial veins results from either pressure effect with blood stagnation or venous trauma [6, 7]. The pressure effect and blood stagnation may result from stretching and relaxation of superficial veins following activities causing repeated movement of the breast and the contracting and relaxing of thoracic wall muscles [6, 7]. Activities contributing to intense thoracoabdominal muscle stretching as it is in bodybuilders and tight bras are attributed to development of Mondor’s disease involving the chest wall [1, 2, 3, 8, 9].
The incidence of Mondor’s disease is unknown with about 400 cases reported worldwide by 2009 and impacting people aged 30–60 years old [10, 11, 12]. Some literature indicates an incidence ratio of Mondor’s disease involving the chest wall of 0.07–0.96% among breast clinic patients ; 1.39% among sexually transmitted disease clinic patients  and 1% after breast cancer surgery and aesthetic mammaplasties . Reviews indicate that a number of cases have been reported in western countries [1, 10, 11]. Limited literature exists on Mondor’s disease in African countries. For instance, only three cases have been reported in Nigeria . In Tanzanian literature, no case of Mondor's disease has been documented to the best of my knowledge.
A 52-year-old Tanzanian woman residing in a rural area reported an insidious appearance of subcutaneous cord-like band which was initially painful and subsequently became painless and associated with tension and skin retraction. The band extended from below the left breast to the thorax and upper abdominal wall. She now sought medical attention because the cord-like band was becoming more visible and more painful initially interfering with normal farming activities. Prior to noticing the cord-like band, she experienced sharp pain at the mid-point between two-thirds of the distance from the umbilicus and the right anterior superior iliac spine disappearing after 2 weeks without any medications. Her past medical history appears insignificant except that she has been hoe-farming throughout her life which involves overexerting the chest wall muscles. She had sought medical care from a semi-secondary healthcare facility a month ago where breast cancer was mistakenly suggested and referred to a tertiary urban facility where she never attended due to financial difficulties.
Mondor’s disease is classified as a rare and self-limiting condition. When the condition involves chest wall, it may present with enragement of superficial veins which may extend to thoracoabdominal wall [1, 2, 3, 4, 5, 8, 9, 10, 11]. Sustained physical exertion of the muscles of the chest wall has been linked to thrombophlebitis of superficial veins leading to Mondor’s disease [6, 9]. In Africa, hoe-farming is among the activities associated with repeated physical exertion of the chest wall. Lifting the hoe, digging and pulling the sand to make an elevated collection of sand for plant cultivation all result in exertion of chest muscles and repeated breast movement among women which may predispose to Mondor’s disease [6, 9]. A shortcoming of diagnostic workout in rural areas is that the disease cannot be better visualised by radiological imaging . However, where access to such technology is limited, failure to recognise the signs and symptoms of Mondor’s disease may lead to wrong diagnosis and unnecessary medicalization of patients. It is important to note that Mondor’s disease is self-limited and the thrombophlebitis usually resolves in 4 to 8 weeks without any specific treatment. Reassurance is highly recommended and antipains where necessary may be beneficial. This report, therefore, is a reminder to medical practitioners in low income rural areas where hoe-farming is prevalent, to include Mondor’s disease as a diagnostic consideration in patients presenting with thrombophlebitis of the superficial veins in the clinical setting.
The author wish to acknowledge clinician and nurses of Inspire Dispensary in Shinyanga, Tanzania, in their contribution throughout case identification and management. The author also thanks clinician and nurses at a neighbouring health centre for their support during case medical records tracking.
All case data can be accessed at Inspire Dispensary. Since the case file contains identifying information and would require data transfer authorization, the author is unable to deposit them online.
Apart from Inspire Dispensary’s staff involved in case identification and management, and medical records follow-up at neighbouring health centre, the author did not receive support in case report development.
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Conflict of Interest
The authors declare that there is no conflict of interest.
Given its nature, the need for ethical approval for this case report was waived.
Informed Consent/Consent for Publication
A written permission to publish the case report without identifying information has been obtained from the patient. Patient photos are not included in this case report.