Case 1: A 55-year-old woman with a history of hypertension and a 20-pack-year history of smoking presents with fever, chills, and breast pain for three days. She woke up three days ago and noticed that her right breast felt extremely swollen. The next day, she felt feverish and noticed that her chest had turned red. She took some paracetamol which slightly improved her symptoms, but today she is in excruciating pain. She denies being pregnant and any similar symptoms in the past. She denies recent weight loss, changes in appetite, or nipple discharge. She states that the area is painful but not itchy. Vital signs are HR 104, BP 130/75, RR 20, SpO2 100% in RA and temperature 38.6°C. Her examination is notable for a 3 cm diameter circular area of erythema, edema, warmth, tenderness, and induration in the medial portion of her right breast. There are no palpable lymph nodes in the armpits or supraclavicular area, and nothing can be removed from the area. There is no ’orange peel’ appearance, your nipples are not retracted and you do not notice any dimples in the area. What would I do next? |
Case 2: A 32-year-old woman, G2P2, with no medical history, who gave birth three weeks ago, presents with pain in her left breast for three days. She is red, swollen and painful. Yesterday she went to her obstetrician-gynecologist, who prescribed cephalexin 500 mg four times a day. She has been taking antibiotics as prescribed, but she does not report any improvement. She is actively breastfeeding and is concerned that this could affect her baby. Vital signs are HR 85, BP 115/70, RR 18, SpO2 100% in RA and temperature 38°C. His examination is notable for a 2 cm diameter round area of erythema, edema, warmth, and induration on the upper lateral portion of his left chest. There is no discharge from the nipple, her nipples are not retracted, she does not have an ’orange peel’ appearance, and no lymph nodes are visible in the supraclavicular or axillary regions. What would be the steps to follow? |
Background
Mastitis in general refers to inflammation of the breast parenchymal tissue and can be broken down into what is known as puerperal mastitis (mastitis in the context of lactation) and non-puerperal mastitis (mastitis not related to lactation).
There are rare cases of granulomatous mastitis that are complications of tuberculosis or sarcoidosis. Breast erythema, pain, and warmth may also be present during breast engorgement or when a duct is blocked, but without systemic symptoms.
The clinical definition of mastitis is generally considered to be an infection of the breast tissue, with the breast "red, swollen, hot and painful in a specific area... and may cause flu-like symptoms such as fever, aches and fatigue ".
Breast abscess is defined as an accumulation of pus in the breast tissue. Breast abscesses often occur as a complication of mastitis. There appears to be a spectrum of breast engorgement, non-infectious mastitis, infectious mastitis, and ultimately breast abscess.
Puerperal mastitis leading to breast abscess is often due to Staphylococcus aureus and Streptococcus infections .
The bacteria usually spread from the baby’s nasal passages or pharynx through a break in the areolar skin of the nipple. Mastitis occurs in 1-24% of breastfeeding women, and breast abscesses occur in 5-11% of breastfeeding women who develop infectious mastitis.
It most commonly occurs within the first 6 weeks of breastfeeding; however, it can occur at any time during breastfeeding. Breast tissue typically appears erythematous, indurated, and feels warm to the touch. Predisposing factors include damaged nipple tissue, lack of feeding, excess milk, poor attachment by the baby, pressure on the breast, maternal stress or fatigue.
Diagnosis/treatment
> Mastitis
Mastitis is a clinical diagnosis. Laboratory tests and diagnostic procedures do not need to be performed routinely. According to the WHO report on mastitis, a breast milk culture should be obtained if:
- No response to antibiotics in 2 days
- Mastitis recurs
- Mastitis is acquired in the hospital
- The patient is allergic to common therapeutic antibiotics.
- These are serious or unusual cases
Treatment of mastitis includes counseling, effective milk removal, antibiotics, and symptomatic treatment. Patients should be assured that they can continue breastfeeding from the affected breast, that it will not affect the baby, and that it will, in fact, help the breast to recover.
They should also receive advice on effective milk removal, which is an essential part of treatment. This includes improving the baby’s latch, frequent breastfeeding (both the frequency and duration of feeding as the baby requires), and, in some cases, the use of hand expression or pumping.
Symptomatic treatment includes nonsteroidal anti-inflammatory drugs and cold compresses. Antibiotics should cover Staphylococcus aureus . First-line antibiotics are dicloxacillin 500 mg orally four times a day for 7-10 days or cephalexin 300-450 mg orally three times a day for 7-10 days.
If patients do not respond to initial treatment, MRSA should be considered and antibiotics should include trimethoprim-sulfamethoxazole orally twice daily for 5-14 days or clindamycin 300 mg orally three times daily for 5-14 days. days.
> Breast abscess
Breast abscess may be concurrent with mastitis or may develop five days to four weeks after the patient has developed mastitis.
The diagnosis of breast abscess is made clinically; Symptoms include swelling of the breast tissue with fever, a tender, fluctuating palpable mass, and fluid accumulation demonstrated on ultrasound.
The other differentials to consider for breast abscess in lactating women include 1) a plugged duct without systemic symptoms, 2) galactocele, which is a non-tender cystic mass, and 3) inflammatory breast cancer which usually has skin thickening, erythema and orange peel.
Women who are not breastfeeding can also develop mastitis and/or breast abscesses. It is important to differentiate mastitis in non-lactating women from inflammatory breast cancer, which is a rare form of breast cancer but can present similarly to mastitis with diffuse erythema and edema of the breast tissue. Mastitis, however, usually causes fever and responds to antibiotics, unlike inflammatory breast cancer.
Smoking is a risk factor for non-puerperal mastitis and abscess formation due to damage to the mammary ducts . In a series of 60 patients with recurrent subareolar breast abscesses, it was found that there is a 26.4 times greater risk of developing breast abscesses in heavy smokers. The pathogens of non-puerperal mastitis are usually Staphylococcus aureus , enterococci , and bacteroides .
For the emergency physician, if mastitis is detected before the development of an abscess, it is appropriate to administer outpatient antibiotics with follow-up with your OB-GYN or primary care physician.
If a patient is not lactating and does not have systemic symptoms, it would be appropriate to consult a radiologist or breast surgeon to ensure that it is mastitis and not inflammatory breast cancer.
In the breastfeeding patient with mastitis, if the patient has had symptoms for less than 24 hours, it is reasonable to encourage her to focus on effective milk expression for a day or two before starting antibiotics.
However, if there is concern of an abscess in breast-feeding or non-breastfeeding patients, drainage and antibiotics are imperative. The physical examination should include a complete examination of the breast tissue, examination of the lymph nodes, evaluation of nipple discharge, and skin examination. Ultrasound can help evaluate for a breast abscess.
Historically, breast abscesses were treated with incision and drainage , often at the bedside. However, this is invasive and often results in scarring, possible structural damage, and poor cosmetic results. Fine needle aspiration under direct visualization is the preferred method of drainage.
Sometimes, repeated aspirations with the needle may be necessary. Abscesses that are larger than 5 cm, have a large volume of pus on needle aspiration, or have a significant delay in treatment are risk factors for needle aspiration failure and may require surgical incision and drainage.
Surgical drainage is appropriate if there is pressure necrosis or ischemia of the overlying skin and/or if the abscess is large and/or there are multiple abscesses.
Emergency physicians often do not drain breast abscesses due to breast tissue sensitivity and cosmetic concerns. If the ED physician is comfortable with needle aspiration, it is a small uncomplicated abscess (usually less than 3 cm) that is not deep, and immediate follow-up is not available, the ED physician may consider performing needle aspiration.
Ideally, patients with abscesses should be referred to breast radiology or breast surgery for drainage of the abscess while the emergency room physician initiates antibiotic treatment, which should include coverage for MRSA.
Conclusion of the case
Case 1: This patient meets the criteria for sepsis with a heart rate of 104 and a temperature of 38.6°C. She orders sepsis protocol labs including blood cultures, complete blood count, basic metabolic panel, and venous blood gases. She has a lactate of 3.5 and you decide she probably needs to be admitted. Start fluids and intravenous vancomycin and order an ultrasound to evaluate for a breast abscess.
Ultrasound shows a 4 cm deep breast abscess. Consult with general surgery and perform needle aspiration under ultrasound guidance. The patient is admitted to the hospital for sepsis. He followed up with the patient, who ultimately needed three aspirations for complete drainage.
If the patient had not met the criteria for sepsis and did not warrant admission, you would have ordered antibiotics on an outpatient basis and arranged for outpatient follow-up with a breast surgeon or breast radiologist for drainage.
Case 2: You clinically diagnose the patient with mastitis given her history of breast pain during breastfeeding accompanied by fever. However, based on her physical examination, she is concerned that she also has an abscess and suspects that this is the reason why she has not responded to the cephalexin prescribed by her OB-GYN. Take a look at the ultrasound and you can see a 2cm collection under the breast tissue.
You arrange for him to follow up the next day with the breast clinic for drainage. The patient fears that this abscess could affect her baby and you assure her that she should continue breastfeeding from the affected breast to improve her mastitis. Have one of the lactation consultants come talk to her to make sure you are optimizing her breastfeeding to decrease the risk of recurrent mastitis.
Highlights
|
