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Breast Abscess

A breast abscess is a collection of pus, formed in a cavity of the breast as a result of inflammation.


Presentation

Abscesses have the shape of a smaller or bigger lump or mass, which may be palpated by the patient themselves or the physician; however, in the majority of the cases this is rendered impossible due to the inflammation. The typical manifestations of mastitis include swelling and redness of breast skin, elevated breast temperature and a painful sensation described by the patient. As any other inflammation, mastitis may be accompanied by fever and nausea, with the patient reporting the exudation of pus from an obvious mass or the nipple.

Fever
  • In enteric fever dissemination to multiple organ systems following bacteraemia can lead to localized abscess.[ncbi.nlm.nih.gov]
  • Clinical Manifestations Acute infection of the breast (abscess) often seen in first-time mothers during the third or fourth week of postpartum breast feeding Symptoms are usually unilateral and characterized by chills and fever and tachycardia The breast[americandragon.com]
Fatigue
  • Fatigue. Chills. Warmness or redness. Malaise. Swelling and pus. Fever. Causes The cause of such an infection is mainly due to a blocked milk duct or entry of bacteria into the breast tissue.[medanta.org]
  • The symptoms are: Painful swelling of the breast; Redness and inflammation of the breast, Pain to the touch and widespread pain, High fever often around 40 C; Strong fatigue.[health.ccm.net]
  • Signs and symptoms of a breast abscess tend to be similar to mastitis and include: Malaise Nausea Extreme fatigue Aching muscles A well-defined tender lump in the breast Pus may be able to be expressed out of the nipple Swelling, pain and redness at the[bellybelly.com.au]
  • Treatment Principle Release Wind-Cold in the exterior and muscle layer Generates Fluids Herb Formulas Points Clinical Manifestations Alternating chills and fever Restlessness Irritability Anorexia Sometimes fatigue Fullness in the chest Dizziness Irritability[americandragon.com]
  • […] hardness, swelling, a sensation of heat in the affected area Fever and chills A general ill feeling Tender lymph nodes under armpits Risk factors The following factors may be associated with breast abscess: Postpartum (after giving birth) pelvic infection Fatigue[health24.com]
Malaise
  • Risks for developing breast abscess include primiparity, birth after 41 weeks' gestation, age 30 years, and recent mastitis. [2,3,4,5] Clinical presentation of lactational breast abscess usually includes fever, chills, malaise, and recent or recurrent[medscape.com]
  • Malaise. Swelling and pus. Fever. Causes The cause of such an infection is mainly due to a blocked milk duct or entry of bacteria into the breast tissue. Women who are not breastfeeding can also develop the disease.[medanta.org]
  • Signs and symptoms of a breast abscess tend to be similar to mastitis and include: Malaise Nausea Extreme fatigue Aching muscles A well-defined tender lump in the breast Pus may be able to be expressed out of the nipple Swelling, pain and redness at the[bellybelly.com.au]
  • Symptoms Breast pain often unilateral often affecting a defined area of the breast pain is often worse before feeding and may feel improved after feeding however the pain can be more intense during feeding, particularly at letdown Malaise Flu-like symptoms[gpifn.org.uk]
  • Always contact your doctor if you have signs of a worsening infection, such as high fever, spreading redness, fatigue, or malaise, much like you would feel if you had the flu.[healthline.com]
Hodgkin Lymphoma
  • Primary non-Hodgkin's lymphoma of the breast is an uncommon disease. In all patients with breast lump, primary lymphoma of breast should be considered as it is one of the most easily missed pathology.[ncbi.nlm.nih.gov]
Plethora
  • Bacteria can originate from the patient's own skin flora, or from the infant's oral cavity, which harbors a plethora of potential pathogens.[symptoma.com]
Axillary Lymphadenopathy
  • Axillary lymphadenopathy, more common in TB, might reflect tuberculosis mastitis. Accurate diagnosis can safely be made only when additional clinical data are present.[pubs.sciepub.com]
  • Axillary lymphadenopathy may be palpable. Investigations Diagnosis is usually clinical. Detection of pathogens in breast milk is not always possible, and the results of milk culture may not be a useful guide for therapy.[patient.info]
  • There was no axillary lymphadenopathy.[themdu.com]
Tachycardia
  • Clinical Manifestations Acute infection of the breast (abscess) often seen in first-time mothers during the third or fourth week of postpartum breast feeding Symptoms are usually unilateral and characterized by chills and fever and tachycardia The breast[americandragon.com]
  • Since beta blockers inhibit the release of catecholamines, these medications may hide symptoms of hypoglycemia such as tremor, tachycardia, and blood pressure changes.![gutfeelingszine.com]
Breast Mass
  • Specimens obtained by fine needle aspiration, incision and drainage, and biopsy of the breast mass all showed acute inflammation and many gram-positive cocci on gram stain and histologic examination; cultures of all specimens yielded many coagulase-negative[ncbi.nlm.nih.gov]
  • The main concern of many women presenting with a breast mass is the likelihood of cancer. Reassuringly, most breast masses are benign. Ultrasonogram demonstrates a hypoechoic mass with smooth, partially lobulated margins typical of a fibroadenoma.[emedicine.medscape.com]
  • The stage of the apparition of an abscess is a late stage in the evolution of an inflammatory breast mass called mastitis. Initially, a simple breast pain and inflammation with a small sensitive area is identified.[health.ccm.net]
Large Breast
  • We report a case of an extremely large breast abscess in a primiparous 20-year-old woman, which presented 6 weeks postpartum.[ncbi.nlm.nih.gov]
  • However, a mass is not always palpable, especially if it is located deep within a large breast. Diagnosis is made via signs and symptoms, physical examination, and ultrasound.[medscape.com]
  • Large breast abscesses For larger breast abscesses, a small incision (cut) is made in the abscess to let the pus drain out. Before the procedure, an injection of local anaesthetic will usually be given to numb your breast tissue.[hse.ie]
Red Breast
  • But if you have an inflamed, sore, swollen or red breast, or if you have the chills or feel like you have the flu, you might have mastitis. If you think you might have mastitis, follow the same steps as for a blocked milk duct.[raisingchildren.net.au]
  • Any patients with a medical history of breast infection, and swollen, red breasts are candidates for mastitis.[symptoma.com]
Nipple Retraction
  • . • Clinical features include breast pain, erythema, peri-areolar swelling and tenderness, and/or nipple retraction and these occur in relation to the affected duct. 7.[slideshare.net]
  • ) General risk factors Smoking Diabetes Obesity Rheumatoid arthritis Medically related risk factors Steroids Silicone/paraffin implant Lumpectomy with radiation Inadequate antibiotics to treat mastitis Topical antifungal medication used for mastitis Nipple[unboundmedicine.com]
Nipple Discharge
  • Sub and periareolar (around the nipple) abscesses also frequently cause nipple discharges.[breast-cancer.ca]

Workup

Mastitis and subsequent breast abscesses cause a clinically evident breast inflammation, which can be diagnosed based solely on clinical manifestations. Any patients with a medical history of breast infection, and swollen, red breasts are candidates for mastitis.

Cultures of breast milk, if a patient lactates, or of the pus produced from the abscess may be required in order to detect the specific pathogen responsible for the condition and arrange the proper antibiotic scheme.

If the diagnosis of a breast abscess cannot be substantiated with clinical observations, ultrasonography can be applied to differentiate between a abscess and a potential tumor. Women who are under antimicrobial treatment for a breast abscess and show no signs of symptom relief despite the medications and women who do not breastfeed should also undergo investigation for the existence of a potential tumor.

Ultrasonography is a useful tool to distinguish an abscess from a malignant formation and also aids the physician in the follow-up stage, allowing for the accurate evaluation of response to therapeutic regimes. Findings that ascertain the existence of an abscess include a hypoechoic collection encased in an echogenic border, lack of vascularization and acoustic enhancement.

Mammography can also be used to eliminate the potential existence of a carcinoma, but is not often performed, as the findings, such as a non-symmetric distortion or density, are not pathognomonic. A mammography is more often carried out in women who have passed the age of thirty, who present with non-bacterial mastitis or remain unresponsive to treatment for long periods of time. Even though the mass cannot be diagnosed accurately via mammography, the latter is the optimal tool for detecting other anomalies consistent with breast cancer, such as calcifications. A biopsy specimen can then be retrieved to confirm.

Pulmonary Infiltrate
  • Despite cloxacilin, then ceftazidime and amikacin, initial improvement was followed 2 weeks later by nodular pulmonary infiltration with cavitation.[ncbi.nlm.nih.gov]
Salmonella Typhi
  • We report here a classical case of Salmonella typhi infection in a rare clinical form of a breast abscess in a non-lactating immuno-compromised female.[ncbi.nlm.nih.gov]
Bartonella Henselae
  • Rarely, mastitis may be a result of microorganisms including fungi, parasites, Bartonella henselae or Brucella, which many times may trigger suspicion of an underlying immunodeficiency and the existence of an HIV infection must be investigated.[symptoma.com]
Fusarium
  • Culture of both FNAs yielded a heavy and pure growth of Fusarium solani. The patient responded to oral ketoconazole 200 mg once daily for 3 weeks. The breast fusariosis reported here is presumably the first case in India.[ncbi.nlm.nih.gov]
Actinomyces Israelii
  • Primary actinomycosis of the breast is an unusual condition, where the most commonly isolated pathogen has been Actinomyces israelii. In recent years, other Actinomyces strains have been found associated with breast disease.[ncbi.nlm.nih.gov]
Mycobacterium Fortuitum
  • Cultures grew Prevotalla melangenica and Mycobacterium fortuitum. She required drainage and antibiotic treatment. Three months into her treatment she stopped her medications, relapsed, and required drainage.[ncbi.nlm.nih.gov]

Treatment

The key point in order to prevent the development of an abscess is to successfully treat the initial mastitis. In this way, the inflammation will be reversed at an early stage and the complication of an abscess will be avoided. Otherwise healthy women are treated with oral antibiotics for 7-10 days. Should the woman be lactating, a physician will prescribe antibiotics that do not cause any additional harm to the infant.

Women who suffer from additional preexisting conditions, such as diabetes or immunosuppression, or women with severe mastitis, usually require the administration of IV antimicrobial agents.

If an abscess has already built up, it is surgically drained by needle with the aid of local anesthesia. Ultrasonographic guidance may be required to prevent damage to nearby healthy tissue. Larger abscesses may need the skin to be incised first, in order for the pus to be drained. While all surgical drainage processes are performed with local anesthesia, general anesthesia may be mandatory if the abscess has reached a considerable depth within the tissue.

Prognosis

Breast abscesses tend to be challenging by means of definitive treatment. When surgically drained, they tend to re-emerge at a rate of 39-50%, whereas a fistulectomy is believed to produce better long-term results, as the abscess recurs after a longer period of time.

Etiology

Breast abscesses form due to mastitis. This term is used to comprehensively describe the inflammation of the breast, regardless of its cause. More specifically, mastitis may be a result of bacterial infection, but may also be caused by non-bacterial causes.

The most typical bacterium leading to an abscess-accompanied mastitis is S. aureus, which is one of the pathogens found amongst the skin's natural flora. Almost all staphylococci isolated from abscesses are methicillin-resistant [1]. The second most common pathogen responsible for a mastitis case is coagulase-negative staphylococcus, followed by a plethora of other aerobes, such as Streptococcus, Enterobacteriae, Escherichia coli etc.

Anaerobic bacteria may also be the culprits behind the infection. Lactobacillus, Clostridium, Veillonella, Bacteroides and other pathogens [2] are responsible for causing a mastitis; it is believed that people with smoking habits tend to be more frequently infected by anaerobes, rather than aerobes, when compared to non-smokers [3]. It has also been estimated that a considerable number of abscesses are formed due to an infection with a combination of different pathogens, both anaerobes and aerobes.

Rarely, mastitis may be a result of microorganisms including fungi, parasites, Bartonella henselae or Brucella, which many times may trigger suspicion of an underlying immunodeficiency and the existence of an HIV infection must be investigated [4].

Lastly, as far as non-bacterial mastitis is concerned, it can occur as a result of foreign material in breast tissue, such as breast implants or piercing, or due to duct ectasia [5]. Idiopathic causes are also possible, as in the case of lobular mastitis [6].

Epidemiology

1-10% of women who engage in lactation tend to develop a mastitis as a result, but the percentage is subject to fluctuations [7].

At a rate of 3-11%, breast abscesses form in patients with underlying mastitis and more specifically, only in a 0.1-3% of lactating women [8]. As for lobular mastitis, whose causes are still unknown, its prevalence is insignificant, as it is an extremely uncommon disorder [9].

Sex distribution
Age distribution

Pathophysiology

Women who lactate develop bacterial mastitis due to two reasons [10]: excessive production of milk which does not flow when the baby is not feeding and a higher risk of cracks and injuries of the nipples, which constitute a breach of the breast skin barrier, allowing for the entrance of skin bacteria. Bacteria can originate from the patient's own skin flora, or from the infant's oral cavity, which harbors a plethora of potential pathogens.

Abscesses that occur due to the process of lactation are usually located distally, as the nipples and the adjacent skin are the points of bacterial entrance. In non-lactating women, abscesses are usually observed in the region beneath the nipple's areola. Generally, irrespective of their causes, abscesses that rupture may lead to the formation of a draining canal and subsequently to a fistula, that is expected to drain pus to the skin region unless treated.

The condition known as duct ectasia involves the dilation of the milk ducts, which is accompanied by a clinically evident inflammation. It is typically linked to squamous metaplasia of the milk ducts, which leads to the obstruction of the ducts themselves and potential rupture. The inflammation causes the ducts to be more susceptible to bacterial pathogens, which complicate the condition by causing an infection [11]. Damaged tissue and annihilated pathogens lead to the formation of pus, which build up to form a breast abscess.

Prevention

One of the crucial factors that should be addressed upon the diagnosis of mastitis is the importance of milk flow. Milk that remains in the breast in a static condition is susceptible to inflammation. Therefore, mothers are advised to breastfeed even if they notice symptoms of inflammation, since it will rid the breast of the contaminated milk and they baby will remain healthy, as the bacteria will be eradicated by the stomach's gastric acid.

Should breastfeeding cause excessive pain, a breast pump can be used to extract the infected milk. A warm compress placed over the inflamed breast fro a quarter of an hour prior to breastfeeding can also enhance the milk's flow and help avoid the formation of an abscess.

Summary

Breast abscesses are collections of pus that have built up beneath breast skin. They are caused by a bacterial infection; activated white blood cells target the pathogen, which is exterminated alongside dead body tissue and pus is produced.

Abscesses are associated with clinically evident inflammation and are by definition painful. Staphylococcus aureus, commonly found in the skin, is the microorganism usually responsible for such an inflammation. It can bypass the skin barrier through any breach of continuity (wounds, cracks etc.) and cause inflammation of the underlying fat and milk ducts, which is defined as mastitis. The annihilation process carried out by components of the immune system destroys S. aureus and the damaged milk ducts and pus is formed, which concentrates in a cavity, thus forming an abscess.

Patient Information

A breast abscess is the collection of pus in a cavity of breast tissue, which develops as a result of infection with various bacteria. A breast abscess will produce symptoms that are essentially easy to recognize by any individual: the infected breast is painful or tender, swollen and red. The patient may also have a fever.

An abscess is a result of infection. A person's skin is naturally endowed with various bacteria (flora), which cause no harm as long as they remain on the outer surface of the skin. If someone sustains a cut, abrasion or crack, these bacteria can bypass the skin and enter tissues, which are not protected against them. This results to inflammation, which, if not treated early, leads to the formation of pus. Pus consists of exterminated bacteria and dead body tissue. Women who breastfeed run a high risk of developing a breast infection, since breastfeeding causes more cracks and injuries to the breast's skin than usual.

If you start feeling symptoms that resemble an inflammation of the breasts, whether you lactate or not, consult your doctor. They are responsible for diagnosing an abscess and can illustrate the therapy plan. You may need oral antibiotics and the abscess may be drained with a needle under local anesthesia

If you are breastfeeding, in order to prevent an abscess from forming, make sure that you wash the breasts daily and remove remaining secretions. Use sterilized cotton or compresses sprayed with boiled water to clean the breasts after feeding your baby and allow them to dry in the air. Apply moisturizing solutions and creams to the breasts to avoid being injured during this period.

References

Article

  1. Moazzez A, Kelso RL, Towfigh S, et al. Breast abscess bacteriologic features in the era of community-acquired methicillin-resistant Staphylococcus aureus epidemics. Arch Surg. 2007;142:881-884.
  2. Efrat M, Mogilner JG, Iujtman M, et al. Neonatal mastitis - diagnosis and treatment. Isr J Med Sci. 1995;31:558-560.
  3. Gollapalli V, Liao J, Dudakovic A, et al. Risk factors for development and recurrence of primary breast abscesses. J Am Coll Surg. 2010;211:41-48.
  4. Pantanowitz L, Connolly JL. Pathology of the breast associated with HIV/AIDS. Breast J. 2002;8:234-243.
  5. Johnson PE, Hanson KD. Acute puerperal mastitis in the augmented breast. Plast Reconstr Surg. 1996;98:723-725.
  6. Al-Khaffaf B, Knox F, Bundred NJ. Idiopathic granulomatous mastitis: a 25-year experience. J Am Coll Surg. 2008;206:269-273.
  7. Betzold CM. An update on the recognition and management of lactational breast inflammation. J Midwifery Womens Health. 2007;52:595-605.
  8. Amir LH, Forster D, McLachlan H, et al. Incidence of breast abscess in lactating women: report from an Australian cohort. BJOG. 2004;111:1378-1381.
  9. Al-Khaffaf B, Knox F, Bundred NJ. Idiopathic granulomatous mastitis: a 25-year experience. J Am Coll Surg. 2008;206:269-273.
  10. Marchant DJ. Inflammation of the breast. Obstet Gynecol Clin North Am. 2002;29:89-102.
  11. Bundred NJ, Dixon JM, Lumsden AB, et al. Are the lesions of duct ectasia sterile? Br J Surg. 1985;72:844-845.

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Last updated: 2019-07-11 21:57