Darwish et al. Journal of Medical Case Reports 2010, 4:267 http://www.jmedicalcasereports.com/content/4/1/267 5 cm in diameter with similar features to the findings in the right breast. A similar mass, 3 cm in diameter, was found within a right accessory axillary breast but no palpable axillary lymph nodes. There were no associated nipple or skin changes. Both accessory axillary breasts tissue contained multiple small masses. The findings of both breasts and axillae were consistent with a clinical diagnosis of fibroadenoma (Figure 1). Full blood count, liver function test, kidney function test, chest X-ray and echocardiogram showed no abnormalities. Serum prolactin level was also within normal range. Bilateral breast and axillary ultrasound examination supported the clinical findings suggestive of multiple fibroadenomas. She underwent excision of multiple bilateral breast and axillary fibroadenomas through multiple skin incisions. She had a good post-operative recovery and wound healing. Histopathological examination of all excised masses confirmed the diagnosis of fibroadenomas. Discussion The association between post-renal transplant cyclo- sporine-A therapy and breast changes is described in the medical literature [1,2]. These changes can be focal or generalized depending on the pathology. Focal changes commonly occur in the form of fibroadenoma, which may be single, multiple, unilateral or bilateral. Low-grade phylloides tumor is another, less common, focal breast change that is associated with cyclosporine- A therapy. A diffuse pattern usually occurs in the form of multiple nodularity, fibrocystic disease or a more uni- form generalized pattern with histological features simi- lar to those found in men with gynecomastia [3,4]. Another form of diffuse breast changes is generalized Figure 1 Photograph showing hugely enlarged right breast and bilateral accessory axillary breast tissue. Page 2 of 3 painful breast hypertrophy. This has to be differentiated from inflammatory breast cancer, infiltrative lymphoma and leukemic breast disease by performing a meticulous triple assessment to excluded malignancy in these patients[3,5]. Cyclosporine is also well known to cause gingival hypertrophy as a direct action of the drug or its metabo- lites on the gingival fibroblasts. A similar mechanism of action may take place in the breast causing breast hypertrophy and fibroadenomata, which could explain the breast changes in our patient. Both cyclosporine-A and feldipine (a calcium antagonist) are reported to induce hypertrophy by causing hyperprolactinemia sup- ported by a raised serum prolactin level post mammo- plasty. The fact that this woman had a normal serum prolactin level makes this explanation less likely. Several cyclosporine-A binding proteins are identified in lym- phoid and non-lymphoid cells [3,6]. These proteins are claimed to be related to the development of T-cell lym- phoma in some patients post renal transplant on cyclo- sporine-A therapy [1]. Discontinuing the cyclosporine may induce some improvement in early cases, but the breast may not return to pre-transplantation size due to the established breast fibrosis. In some patients where the degree of gynecomastia is small and/or the abnormalities are focal as fibroadenomas, which can be removed surgically, modification of immunosuppressive regimen is usually not necessary. However, in our patient with the pre- sence of multiple fibroadenomas in every breast tissue including the accessory breasts in addition to the gingi- val hypertrophy, a shift to another immunosuppressive agent (tacrolimus) was found to be a reasonable decision. Conclusions Cyclosporine-A therapy is associated with breast fibro- blast proliferation and breast fibroadenoma. Awareness of the association between cyclosporine-A and fibroade- nomas should help to achieve the correct diagnosis in patients post transplantation without subjecting them to unnecessary procedures. Early conversion to tacrolimus should be considered in patients who appear to be developing cyclosporine-A induced breast disease and gingival hypertrophy. Competing interests The authors declare that they have no competing interests. Authors’ contributions AD was involved in the diagnosis and management of the patient. AON was involved in data collection and writing of the manuscript. LAEH was involved in the tissue diagnosis and literature search necessary for this manuscript. AHF is the senior surgeon supervised diagnosis, management and writing of this manuscript. All authors have read and approved the final manuscript.