A Rare Cause of Breast Pain in Primary Care: Mondor’s Disease Diagnosed in a Family Medicine Clinic

Abstract

Mondor’s disease is a rare disease that presents as a superficial thrombophlebitis that most often occurs in breast tissue, but can also occur on the anterior chest wall, thoracoabdominal region, and even the penis. Mondor’s disease generally presents as localized pain and a palpable cord-like structure. It is a benign and self-limiting disease that can be managed conservatively and typically resolves in about four weeks without any treatment. This condition is important to recognize clinically because it can easily be mistaken for lymphangitis, cellulitis, musculoskeletal chest wall pain, breast mass, or malignancy.

We present the case of a 58-year-old female who presented to the family medicine clinic with a several-day history of bilateral breast pain. The patient had a prompt mammogram that was negative and breast ultrasound imaging that revealed a small thrombus in the left breast, suggesting Mondor’s disease as the culprit. The patient was treated conservatively and provided with close breast ultrasound follow-up. The patient’s symptoms improved and resolved over 12 weeks.

This case highlights the importance for primary care physicians to remain attentive to red flags requiring further investigation and recognize Mondor’s disease in primary care.

Introduction

Mondor’s disease is a rare and benign condition. The condition was first described by Henri Mondor in 1939 and remains a rare diagnosis in routine clinical practice [1]. There are few case reports regarding this disease because it has a quick self-limiting duration [2,3]. Mondor’s disease is characterized by superficial thrombophlebitis of subcutaneous veins [4]. It most commonly affects the anterior chest wall, breast, or thoracoabdominal region, although it may occur in other anatomical areas, including the penis [5-13]. 

The typical clinical presentation is a tender, palpable, cord-like structure beneath the skin, often following the course of a superficial vein [14]. Although Mondor’s disease is benign, the clinical findings from initial evaluation often raise suspicion for malignancy or infection [15-29]. This is clinically important in family medicine because Mondor's disease can present similarly as a common complaint in the outpatient setting and at the same time share similarities with other breast pathology that may not always require immediate imaging. Nevertheless, the presence of a palpable cord-like structure may lead clinicians to consider Mondor’s disease and facilitate prompt consideration for the use of imaging that may support diagnostic clarification and also exclude clinically significant but less apparent underlying diseases. This, in turn, can avoid unnecessary treatment, such as use of anticoagulants or antibiotics or other medications that may result in unwanted side effects and harm.

This case report emphasizes the clinical recognition, differential diagnosis, conservative management, and follow-up considerations relevant to primary care.

Case presentation

The patient is a 58-year-old Hispanic female who presented to the family medicine clinic with left breast pain and darkening of the left nipple that lasted for a few days. The patient immediately sought care out of fear she may have breast cancer. The patient denied any injuries or trauma to her breasts. The patient also denied fever, chills, shortness of breath, pleuritic chest pain, recent surgery, recent breast procedures, and intravenous drug use. She does not have any personal history of blood clots, history of thromboembolism, thrombophilia, or any hematologic disorders. No family history of blood clot disorders either. The patient was not pregnant at the time of evaluation, but did previously take progesterone and Premarin briefly for menopausal symptoms a few months prior.

The patient’s past medical history was significant for papillary carcinoma status post right hemithyroidectomy in 2019, menopause, pre-diabetes, anxiety, post-traumatic stress disorder (PTSD), insomnia, and migraines without aura. The patient has been under the care of endocrinology since her right hemithyroidectomy. The patient does not currently take any medications. She previously trialed amitriptyline and rizatriptan for two to three weeks, but this was prescribed for her migraines after her Mondor's disease had already resolved. The patient did trial Premarin and progesterone for vaginal dryness in 2023, but ceased therapy after experiencing paradoxical worsening of vasomotor symptoms including hot flashes. The patient subsequently sought care from a naturopath. The patient reported briefly re-trialing Premarin and progesterone on or about April 2025 for another two to three weeks, but discontinued the medications after developing the same side effects she did in 2023. Her breast symptoms developed approximately six months after her last use of Premarin and progesterone. The patient does not have any family history whatsoever. The patient does not smoke cigarettes or smoke marijuana. She drinks occasional alcohol. The patient’s past surgical history includes partial thyroidectomy, cyst removal on the back, tonsillectomy, and bilateral tubal ligation.

Physical examination revealed a tender mass in the left upper breast at the 11 to 12 o’clock position with dimpling of the skin and darkening of the left nipple with a small area of induration. No erythema, lymphadenopathy, nipple discharge, scaling, or fluctuance was noted on physical exam. She was also afebrile and hemodynamically stable. Initial differential diagnosis included breast malignancy and mastitis/abscess. Therefore, the patient was immediately sent for a bilateral digital mammogram and a bilateral ultrasound of the breasts. Although biopsy was considered a possible next step, breast imaging was first required to further characterize the abnormality and guide subsequent management.

Results of the mammogram were negative for malignancy. The left breast ultrasound results showed: 1. On the left breast at the 11 to 12 o’clock position, 2.0 cm from the nipple, a tubular structure coarsening towards the nipple, which was partially filled with echogenic material (Figures 1, 2). This was favoured to represent a partially thrombosed vessel with a high likelihood of Mondor’s disease.

Figure 1. Initial Ultrasound of the Left Breast at 11-12 O'Clock Palpable Area Showing a Partially Filled Tubular Structure With Echogenic Material Coarsening Towards the Nipple.

Figure 2. Initial Ultrasound of the Left Breast With Doppler at 11-12 O'Clock Palpable Area Showing a Partially Filled Tubular Structure With Echogenic Material Coarsening Towards the Nipple.

The recommendation was to repeat a left breast ultrasound in six weeks due to the abnormal findings found in the left breast. No anticoagulation treatment was initiated since there was no evidence of deep venous thrombosis or systemic thromboembolic disease. The patient was treated conservatively, provided with reassurance, and told to have close follow-up with repeat breast ultrasounds. She was also provided with a recommendation for use of nonsteroidal anti-inflammatory medication as needed for pain.

The patient had a repeat left breast ultrasound 6 weeks after her initial ultrasound, which revealed trace flow, decreased from prior exam (Figures 3, 4), with recommendation to get a third repeat ultrasound in six weeks time thereafter.

Figure 3. Follow-up Ultrasound of the Left Breast at 11-12 O'Clock Palpable Area Six (6) Weeks After the Initial Ultrasound Showing a Partially Filled Tubular Structure With Echogenic Material Coarsening Towards the Nipple.

Figure 4. Follow-up Ultrasound of the Left Breast at 11-12 O'Clock Palpable Area Six (6) Weeks After the Initial Ultrasound Showing a Partially Filled Tubular Structure With Echogenic Material Coarsening Towards the Nipple With Trace Flow Demonstrated At Distal Aspect Decreased Compared to Prior Ultrasound.

Her pain had improved as well during this time. The third ultrasound performed 12 weeks later revealed no soft tissue abnormality and no thrombus. The thrombophlebitis had resolved (Figures 5, 6). She denied any further breast pain. The patient’s symptoms improved and resolved over 12 weeks. The patient was advised to return if symptoms recurred or new thromboembolic symptoms developed. The patient is now under the regular breast screening program where she lives in Ontario, Canada.

Figure 5. Third Follow-Up Ultrasound of the Left Breast at 11-12 O'Clock Palpable Area Twelve (12) Weeks After the Initial Ultrasound With No Identifiable Soft Tissue Abnormality.

Figure 6. Third Follow-Up Ultrasound of the Left Breast at 11-12 O'Clock Palpable Area Twelve (12) Weeks After the Initial Ultrasound With Trace Doppler With No Identifiable Soft Tissue Abnormality.

Discussion

French surgeon Dr. Henri Mondor described Mondor’s disease in 1939 [1]. It is an elusive disease with an unclear pathophysiology and has been reported to affect middle-aged females more often than males, with a peak incidence age of 43 [2-5].

Case reports for Mondor’s disease have shown to involve areas, such as the chest wall, abdomen, penis, groin, upper limbs, and breasts [6-11]. Many case reports have shown that the large majority of patients with Mondor’s disease present unilaterally on either the right or the left side of the abdominal chest wall or breasts [12,13].

Recently developed immunohistochemical markers have revealed that almost all cases of Mondor’s disease are thrombophlebitis of a superficial vein, although a few cases are due to lymphangitis [14]. Immunohistochemical staining for CD31 and D240 has been identified recently as the best method to distinguish small veins from lymphatic vessels [15]. However, these laboratory markers are not routinely ordered in clinical practice, especially in the primary care setting.

Sources have pointed to a progression of acute phlebitis primarily from thrombotic events in the affected veins, resulting in occlusion of the vein with fibrin and inflammatory cells, thereby forming a hard, tender, cord-like induration. This in turn forms a thrombophlebitis and sclerosis with recanalization or obliteration of the vein [4,14]. 

Mondor’s disease can appear spontaneously and is most commonly idiopathic. However, it can occur in breast cancer and as an uncommon complication from breast and axillary surgery, including oncological surgery and aesthetic implants [15-17]. While Mondor’s disease is typically benign and self-limiting, it has occasionally been reported in association with underlying breast malignancy. Some studies have reported underlying breast cancer in up to 12.7% of Mondor's disease cases [18-20]. However, this estimate is based on limited evidence, including case reports and small retrospective series. This, in turn, may overestimate the true contemporary risk due to selection and publication bias. Accordingly, the percentage should be interpreted cautiously rather than as a definitive risk estimate. 

Other risk factors for the manifestation of the disease include excessive physical activity, tight-fitting bras, mastitis, rheumatoid arthritis, febrile illness, intravenous drug use, pregnancy, oral contraceptive use, hormone therapy, vasculitis, thrombophilia, hypercoagulable states, and smoking [3,13,18,21-24]. There are case reports that have also suggested a link between Mondor's disease, specifically in the penis, and COVID-19 [25-27]. This patient had used progesterone and Premarin, which could explain the cause for her to have Mondor’s disease. However, she only took those medications briefly, and it is not clear if this had any role in the manifestation of her disease. Moreover, association with hormone therapy remains speculative because no thrombophilia evaluation or causal assessment was performed. Only breast imaging was performed. In hindsight, blood work may have been a good adjunct in workup, but no standard laboratory studies exist to directly test for this disease.

Although laboratory studies can be beneficial to rule out any possible systemic disorders, this condition is generally a benign and self-limiting process. Therefore, extensive investigation is usually not needed and only clinically indicated if there are recurrent symptoms or episodes of thrombophlebitis [15,28].

Imaging with ultrasound is the first step towards the diagnosis of Mondor’s disease and is superior to mammography for the visualisation of thrombophlebitis and thus, Mondor's disease [4,18]. When a patient presents with the aforementioned symptoms, radiological imaging must be made initially in order to avoid a misdiagnosis. Mondor’s disease should not be considered the top diagnosis, but should nevertheless be included as a differential diagnosis.

There has been a case report where the diagnosis of Mondor’s disease of the breast was made purely based on clinical history and examination without imaging, and the patient was found to have invasive ductal carcinoma on subsequent follow-up [6,29]. This again highlights the need for breast imaging as the first step.

Differential diagnosis of Mondor′s disease includes, but is not limited to, cellulitis, lymphangitis, lymphangioma, erythema nodosum, and breast cancer [5]. Hence, breast imaging is so critical.

Systemic anticoagulation is not routinely indicated for superficial thrombophlebitis and is not recommended for Mondor’s disease [30]. Mondor’s disease is a self-limiting and benign disease, which resolves spontaneously within four to six weeks without the use of anticoagulation [6]. However, systemic anticoagulation has been used in isolated instances with success, but there are not sufficient case reports or studies to justify its use ubiquitously. Mondor’s disease is underreported and has a quick self-limiting course, hence why the use of anticoagulation is not the standard of care for Mondor’s disease [4]. It is difficult to determine whether anticoagulation plays any role whatsoever in the resolution of the disease process [4,31].

This case is particularly important for family physicians in primary care because it illustrates how a rare condition may present first in the community setting as a common and anxiety-provoking complaint: breast pain. It also highlights that the recognition of Mondor’s disease should not lead to premature reassurance when concerning breast findings are present. Appropriate imaging remains the crucial first step, especially when there is nipple change, a palpable mass, persistent symptoms, recurrent disease, or diagnostic uncertainty. Early recognition with imaging can rule out other high-acuity diseases such as malignancy and also reduce patient anxiety, avoid unnecessary anticoagulation, avoid unnecessary use of antibiotics, and avoid invasive interventions, which would ensure that serious breast pathology is not missed.

A family physician’s role is not only to recognize the possibility of Mondor’s disease, but also to promptly investigate red flags, provide clear reassurance once malignancy and infection are excluded, and arrange appropriate follow-up to confirm clinical and radiologic resolution.

Conclusions

Mondor’s disease is rare and benign but is an important diagnosis to consider in primary care. It should be considered when a patient presents with localized chest wall, breast, or thoracoabdominal discomfort and a palpable superficial cord-like structure. Although the condition is self-limited, it may mimic infection, musculoskeletal disease, lymphangitis, or breast pathology. This disease may present as a common complaint in primary care and should be considered as a differential diagnosis. Family physicians should recognize the typical clinical features, pursue imaging when concerning features are present, and manage uncomplicated cases conservatively. The takeaway from this case report is not to accurately diagnose Mondor’s disease immediately at the outset, but rather to recognize warning signs, order imaging, and understand the next steps that involve conservative management.