Breast Abscess and Mastitis Case File

Breast Abscess and Mastitis Case File

Eugene C. Toy, MD, Patti Jayne Ross, MD, Benton Baker III, MD, John C. Jennings, MD

CASE 26

A 20-year-old parous woman complains of right breast pain and fever. She states that 3 weeks previously, she underwent a normal spontaneous vaginal delivery. She had been breastfeeding without difficulty until 2 days ago, when she noted progressive pain, induration, and redness to the right breast. On examination, her temperature is 102°F (38.8°C), blood pressure is 100/70 mm Hg, and heart rate is 110 beats per minute. Her neck is supple. Her right breast has induration on the upper outer region with redness and tenderness. There is also significant fluctuance noted in the breast tissue. The abdomen is nontender and there is no costovertebral angle tenderness. The pelvic examination is unremarkable.

» What is the most likely diagnosis?

» What is your next step in therapy?

» What is the etiology of the condition?

ANSWER TO CASE 26:

Breast Abscess and Mastitis                                           

Summary: A 20-year-old breast-feeding woman who is 3 weeks’ postpartum complains of right breast pain and fever of 2 days’ duration. She notes progressive pain, induration, and redness in the right breast. Her temperature is 102°F (38.8°C). There is also significant fluctuance noted in the right breast.

• Most likely diagnosis: Abscess of the right breast.
• Next step in therapy: Incision and drainage of the abscess and antibiotic therapy.
• Etiology of the condition: Staphylococcus aureus.

ANALYSIS

Objectives

1. Know the clinical presentation of postpartum mastitis.
2. Know that S. aureus is the most common etiology in postpartum mastitis.
3. Understand that the presence of fluctuance in the breast probably represents an abscess that needs incision and drainage.

Considerations

This woman is 3 weeks’ postpartum with breast pain and fever. This is a typical presentation of a breast infection, since mastitis usually presents in the third or fourth postpartum week. Induration and redness of the breast accompanied by fever and chills are also consistent. The treatment for this condition is an antistaphylococcal agent such as dicloxacillin. Provided that the offending agent is not methicillin resistant, improvement should be rapid. Affected women are instructed to continue to breast feed or drain the breast by pump. This patient has fluctuance of the breast that speaks for an abscess, which usually requires surgical drainage and will not generally improve with antibiotics alone. If there is uncertainty about the diagnosis, ultrasound examination may be helpful in identifying a fluid collection.

APPROACH TO:

Breast Infections                                           

DEFINITIONS

MASTITIS: Infection of the breast parenchyma typically caused by Saureus.

BREAST ABSCESS: The presence of a collection of purulent material in the breast, which requires drainage.

GALACTOCELE: A noninfected collection of milk due to a blocked mammary duct leading to a palpable mass and symptoms of breast pressure and pain.

CLINICAL APPROACH

Postpartum breast disorders and infections are common. They include cracked nipples, breast engorgement, mastitis, breast abscesses, and galactoceles. Cracked nipples usually arise from dryness, and may be exacerbated by harsh soap or watersoluble lotions. Treatment includes air drying the nipples, washing with mild soap and water, the use of a nipple shield, and the application of a lanolin-based lotion.

Breast engorgement is usually noted during the first-week postpartum and is due to vascular congestion and milk accumulation. The patient will generally complain of breast pain and induration, and may have a low-grade fever. Infant feedings around-the-clock usually help to alleviate this condition. Fever seldom persists for more than 12 to 24 hours. Treatment consists of a breast binder, ice packs, and analgesics.

Postpartum mastitis is an infection of the breast parenchyma, affecting about 2% of lactating women. These infections usually occur between the second and fourth week after delivery. Other signs and symptoms include malaise, fever, chills, tachycardia, and a red, tender, swollen breast. Importantly, there should be no fluctuance of the breast, which would indicate abscess formation. The most commonly isolated organism is S. aureus, usually arising from the infant’s nose and throat. The treatment for mastitis should be prompt to prevent abscess formation, consisting of an antistaphylococcal agent such as dicloxacillin. If the patient has a penicillin allergy, then clarithromycin orally for 10 to 14 days has been effective. For MRSA, clindamycin or trimethoprim/ sulfa orally for 10 to 14 days has been used as empiric therapy pending cultures. Breastfeeding or pumping should be continued to prevent the development of abscess. A culture of the breast milk sent prior to initiating treatment is useful for determining bacterial sensitivities and nosocomial surveillance.

About 1 in 10 cases of mastitis is complicated by abscess, which should be suspected with persistent fever after 48 hours of antibiotic therapy or the presence of a fluctuant mass. Ultrasound examination may be performed to confirm the diagnosis. The purulent collection is best treated by surgical drainage, or alternatively by ultrasound-guided aspiration; antistaphylococcal antibiotics should also be used.

The galactocele or milk-retention cyst is caused by blockage of a milk duct. The milk accumulates in one or more breast lobes, leading to a nonerythematous fluctuant mass. They usually resolve spontaneously, but may need aspiration.

Breastfeeding has many benefits (Table 26– 1). Breast milk contains nearly all of the nutrients required with the exception of several vitamins (K and D), and is more easily tolerated than formula. The infant has a strong suckling reflex in its first hour of life. For this reason, the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics (AAP) recommend that that a healthy baby have a skin-to-skin contact with the mother immediately after delivery with an encouragement for breastfeeding.

COMPREHENSION QUESTIONS

26.1 A 32-year-old woman has just delivered a 40-week baby vaginally. Her physician recommends that she should not breastfeed because of a medical condition. Which of the following conditions is most likely to be present?

A. Ampicillin therapy for cystitis

B. Maternal Dilantin therapy for seizure disorder

C. Maternal human immunodeficiency virus (HIV) infection

D. Maternal inverted nipples

26.2 A 22-year-old nulliparous woman is noted to have a tender, red, right breast and enlarged, tender axillary lymph nodes that have persisted despite antibiotics for 3 weeks. She denies manipulation of her breasts and is not lactating. Which of the following is the most appropriate next step?

A. Course of oral antibiotic therapy

B. Sonographic examination of the breasts

C. Mammographic examination of the breasts

D. Check the serum prolactin level

E. Biopsy of the breast

26.3 A 28-year-old G1P1 woman has delivered vaginally 3 weeks ago. She is breastfeeding and notes that the baby prefers to breastfeed from the right breast. On the left breast, she notes a 3-day history of a tender mass on the upper outer quadrant. On examination, she is afebrile. The left breast has a fluctuant mass of 4 × 8 cm of the upper outer quadrant without redness. It is somewhat tender. Which of the following is the best treatment for this condition?

A. Oral antibiotic therapy

B. Oral antifungal therapy

C. Bromocriptine therapy

D. Aspiration

E. Mastectomy

26.4 A 29-year-old G1P1 woman desires to breastfeed her infant, which is 1 day old. The infant received an injection of vitamin K. You counsel the patient on positive health consequences of breastfeeding, including immunological, bonding, neurodevelopmental, and gastrointestinal (GI) effects. Which of the following requires supplementation in the first 6 months as it is not present in breast milk?

A. Iron

B. Vitamin D

C. Vitamin E

D. Vitamin K

ANSWERS

26.1 C. Maternal HIV infection is a contraindication for breastfeeding because the neonate may contract the infection from infected breast milk. Dilantin and ampicillin are safe to take during pregnancy. Though challenging, women with inverted nipples are still able to breastfeed. There are very few contraindications to breastfeeding: infants with classic galactosemia (galactose 1-phosphate uridyltransferase deficiency), mothers who have active untreated tuberculosis disease or HIV infection, mothers who are receiving diagnostic or therapeutic radioactive isotopes or have had exposure to radioactive materials, mothers who are receiving antimetabolites or chemotherapeutic agents or a small number of other medications until they clear the milk, mothers who are using drugs of abuse (“street drugs”), and mothers who have herpes simplex lesions on a breast.

26.2 E. This woman has had persistent tenderness and redness of the breast despite not lactating and not having trauma to the breast; these symptoms have worsened despite antibiotic therapy. There is a concern about inflammatory breast carcinoma (see Case 47), and she should undergo biopsy. Inflammatory breast cancer presents with redness, tenderness, and warmth and can mimic mastitis. It is an aggressive type of malignancy with cancer cells located in the skin lymphatics.

26.3 D. This patient has a galactocele. It is not an abscess since there is no fever or redness, although untreated, this could become an abscess. The best treatment of a galactocele (milk-retention cyst) is aspiration if it does not resolve spontaneously. This is done to prevent a breast abscess. A galactocele forms when a milk duct is blocked and the milk accumulates in one or more breast lobes, leading to a nonerythematous fluctuant mass. It is not an infection, therefore antibiotics and antifungals are unnecessary; it is also not cancerous, so a mastectomy is not indicated. Bromocriptine is an ergot alkaloid that blocks the release of prolactin from the pituitary (typically in the setting of a prolactinoma), mostly as an attempt to allow a woman to be able to have normal menstrual cycles.

26.4 B. Vitamin D should be supplemented at 2 months of age. The American Academy of Pediatrics recommends that unless contraindicated, each infant be breastfed exclusively for the first 6 months of life because of the health benefits to the baby. Breast-fed babies have less infections including meningitis, urinary tract infections, and sepsis thought to be due to immunoglobulin and leukocytes in the breast milk. They have slightly better neurodevelopmental outcomes, and there is evidence of less risk of diabetes and childhood obesity in later life. Breast milk consists of two proteins, whey and casein, and has lower casein proportion than formula milk, allowing for easier digestion. Lactoferrin (inhibits certain iron-dependent bacteria of the GI tract), secretory IgA, and lysozyme (enzyme which protects against Escherichia coli and other bacteria) are also found in breast milk, along with fats and carbohydrates (lactose). All the vitamins are found in breast milk provided the mother’s nutrition is sufficient, with the exception of vitamin D. The AAP recommends supplementation of vitamin D drops at 2 months of age for infants exclusively breastfed.

    CLINICAL PEARLS    

» The best treatment for postpartum mastitis is an oral antistaphylococcal antibiotic, such as dicloxacillin, and continued breastfeeding or pumping. » The presence of fluctuance in a red, tender, indurated breast suggests abscess, which needs surgical drainage. » The best treatment of cracked nipples is air drying and the avoidance of using a harsh soap. » Breast engorgement rarely causes high fever persisting more than 24 hours.

REFERENCES

American College of Obstetricians and Gynecologists. Breast-feeding: maternal and infant aspects. ACOG Committee Opinion 361. 2007. (Reaffirmed 2013.) 

Cunningham FG, Leveno KJ, Bloom SL, Hauth JC, Rouse DJ, Spong CY. The puerperium. In: Williams Obstetrics. 24th ed. New York, NY: McGraw-Hill; 2014:652-654. 

Hobel CJ, Zakowski M. Normal labor, delivery, and postpartum care: anatomic considerations, obstetric and analgesia, and resuscitation of the newborn. In: H acker NF, Gambone JC, Hobel CJ, eds. Essentials of Obstetrics and Gynecology. 5th ed. Philadelphia, PA: Saunders; 2009:91-118.

HomeObstetrics and Gynecology Case FileBreast Abscess and Mastitis Case File