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Mastitis

Inflammation of the Breast

Mastitis is defined as the inflammation of breast tissues. The breast is made up of several glands and ducts that are directed towards the areola and nipple. These ducts are responsible for carrying milk. When these ducts get blocked or invaded by bacteria, it leads to the condition.


Presentation

The commonest complaint of patients with mastitis is pain. There is also localized breast erythema and the area affected may be febrile to touch. Patients may also develop fever which may be associated with chills and rigor. Lactating mothers may report episodes where have been unable to feed their babies. Mastitis sometimes develop into breast abscesses [5].

Axillary Lymphadenopathy
  • Here we report 3 cases of adult female ranging from 27 to 35 years who presented with 1 to 4 months history of firm lumps in both breasts and no axillary lymphadenopathy.[ncbi.nlm.nih.gov]
Constitutional Symptom
  • One year later she developed severe constitutional symptoms, sicca symptoms, lymphadenopathy, anemia, and interstitial lung disease. Serologies and minor salivary gland were consistent with the diagnosis of SS.[ncbi.nlm.nih.gov]
Rhinitis
  • A 30 years old non diabetic female presented with bilateral breast lumps with history of rhinitis off & on and peripheral eosinophilia. Mammography was suspicious while ultrasonography was diagnostic of bilateral mastitis.[ncbi.nlm.nih.gov]
Xerostomia
  • Lacrimal and salivary glands are the most commonly involved causing keratoconjunctivitis sicca and xerostomia. A wide variety of other glandular and extraglandular manifestations can occur in SS.[ncbi.nlm.nih.gov]
Thigh Rash
  • Failure to respond to standard treatments, development of new breast masses, and discovery of a concurrent ulcerating thigh rash with similar histologic findings as the breast masses prompted further investigation, which ultimately lead to the diagnosis[ncbi.nlm.nih.gov]
Breast Mass
  • Failure to respond to standard treatments, development of new breast masses, and discovery of a concurrent ulcerating thigh rash with similar histologic findings as the breast masses prompted further investigation, which ultimately lead to the diagnosis[ncbi.nlm.nih.gov]
  • Here, we report the case of a 47-year-old woman with an 18-year-long history of SLE, who presented with a suspicious breast mass.[ncbi.nlm.nih.gov]
  • The breast mass disappeared with steroid therapy. When patients have a breast mass, regardless of the presence or absence of IgG4-RD, IgG4-related mastitis should be considered in addition to breast cancer.[ncbi.nlm.nih.gov]
  • It is well documented that surgery may worsen the condition; therefore, it is important to consider LM in the differential of a palpable breast mass in patients with systemic lupus erythematosus (SLE).[ncbi.nlm.nih.gov]
  • We report a case of a 43-year-old woman with a four-year history of arthralgias and positive antinuclear antibodies who developed a right painless breast mass. Biopsy revealed lymphocytic mastitis with predominant B cells.[ncbi.nlm.nih.gov]
Nipple Discharge
  • There may also be nipple discharge. Diagnosis: This is usually done by the doctor after an examination. Laboratory investigations may be ordered like blood tests and the nipple discharge will be checked for bacteria or other organisms.[symptoma.com]
  • A 28-year old male presented to our clinic complaining of a recent onset of a painful right breast lump with redness and nipple discharge.[ncbi.nlm.nih.gov]
  • Mastitis symptoms can include: Nipple discharge. A red or swollen area on the breast. A hard lump or area in the breast. Flu-like symptoms including aches, chills, and tiredness. Cleveland Clinic News & More Cleveland Clinic News & More[my.clevelandclinic.org]
  • discharge , which may be white or contain streaks of blood You may also experience flu -like symptoms, such as aches, a high temperature (fever), chills and tiredness.[nhs.uk]
  • Nipple discharge - which may be white or may contain streaks of blood. Over half of women with mastitis may also experience flu-like symptoms such as: Aches. High temperature (fever) of 38 C (100.4F) or above. Shivering and chills. Tiredness.[bounty.com]

Workup

Diagnosis of mastitis can usually be made by a detailed history and physical examination. However, laboratory investigations may be ordered like complete blood count and differentials to get the blood picture. Also, part or the nipple discharge may be sent for microscopy culture and sensitivity.

Ultrasound is a very important investigations as it helps to confirm a collection in the case of an abscess. It will also assist in obtaining a needle aspirate and it rules out other differential diagnoses [6]. A mammogram should also be ordered to rule out other mimicking conditions.

Treatment

First line treatment is home care and it involves massaging the affected area with warm compress, showers, frequent feeding, adequate hydration, avoiding tight clothing, proper emptying of breasts, and offering the alternate breast after each feed. Expression of milk in between feeds so that the milk doesn’t clog in the ducts can also relieve the symptoms.

Antibiotics are also used depending on the causative organisms. The most common ones are amoxicillin and cephalexin which are effective against Staphylococcus aureus. Vancomycin is used in methicillin-resistant strains [7].

Analgesics are used to relieve pain and are used carefully in lactating mothers. There is new evidence to show that administering lactobacilli, a commonly occurring normal flora in breast milk helps to prevent infectious mastitis in breastfeeding women. If it develops into an abscess, an incision and drainage is done [8].

Prognosis

Mastitis is completely treatable in most cases. Patients experience complete resolution of symptoms within 3 weeks of antibiotic use. If symptoms persists beyond 5 weeks, a resistant infection or malignancy should be considered.

Etiology

The cause of mastitis is either infectious or non-infectious. Infectious causes are bacterial and implicated pathogens include Staphylococcus aureus, Streptococcus spp, Escherichia coli, Salmonella and Mycobacteria. Candida and Cryptococcus have also been identified in rare instances. Bacteria enter the duct usually through a crack in the nipple. Recent studies however suggest that pathogens may actually play a slightly less important role than initially thought.

Mastitis can also be caused by blocked ducts. This can be brought about by incomplete emptying of breasts due to milk stasis or incorrect feeding techniques. Wearing of tight fitting or ill-fitting bras can compress the breast and lead to this condition. It can also result from trauma like a seat belt injury, contamination of breast implants or piercings [2].

Epidemiology

Mastitis is a problem in lactating women and affects as much as 10% of breastfeeding mothers globally. Most episodes of mastitis occur in third or fourth week postpartum and 95% of cases are reported within three months postpartum [3].

Sex distribution
Age distribution

Pathophysiology

Mastitis results from poor milk drainage rom the ducts. There are two forms of mastitis, the first is an acute form and it may present as an abscess in the breast. The chronic form is usually a secondary manifestation of underlying systemic diseases that leads to colonization with pathogens which are rare in healthy women.

During an acute phase, plasma cells, fatty acid crystals and leukocytes get accumulated in the duct spaces and result in a painful, swollen lump. There could also be a whitish discharge noticed from the nipple [4].

Mastitis in elderly patients if untreated for long leads to the formation of granular tissue.

Prevention

Mastitis can be avoided by staying well hydrated and taking plenty of rest. Feeding frequently is encouraged and milk should be expressed whenever the breasts feel full. Proper latching of baby on the breast should also be practiced. Proper nipple hygiene should be taught to lactating mothers due to the increased risk of nipple cracks. Exclusive breastfeeding also helps to reduce the risk [9].

Summary

Mastitis is a common condition among breastfeeding women (puerperal mastitis or lactational mastitis). Its primary cause is bacterial although there are other causes. It is a painful condition and usually leads the mother to discontinue breastfeeding which may compromise infant nutrition and lead to hyponatremia. Mastitis is very rare in men [1].

Patient Information

  • Definition: Mastitis is an infection or inflammation of the breast. It commonly occurs in breastfeeding women although it can be seen in normal women. It arises often due to infection of blocked milk ducts due to milk stasis. Women with underlying diseases are also prone to developing this condition. 
  • Cause: The primary cause of mastitis is poor or incomplete drainage of the ducts in the breast. This stasis on its own causes an inflammatory reaction. It could also be caused by bacterial proliferation of this blocked ducts. Bacteria could also enter the ducts through a crack in the nipple of lactation mothers. Wearing tight and poor fitting bras and injuries like from a seat belt can also cause it.
  • Symptoms: The commonest symptom is breast pain. There may also be localized redness and the area will be warm when touched. Breasts could also be swollen. Patient may develop fever along with chills and breastfeeding mothers may not be able to breastfeed their babies. There may also be nipple discharge.
  • Diagnosis: This is usually done by the doctor after an examination. Laboratory investigations may be ordered like blood tests and the nipple discharge will be checked for bacteria or other organisms. Ultrasound may also be performed to check if there is an abscess or other conditions.
  • Treatment: Anti-inflammatory drugs like Paracetamol, Diclofenac, and Ibuprofen may provide relief from symptoms of pain and redness. Regular massaging of breasts can be done to relieve pain. Warm showers or warm compress may release the blocked milk ducts. Changing the position of baby during each feed and ensuring the correct latching by baby can also help in case of mastitis. Antibiotics are also given to eradicate the bacteria and mastitis usually resolves in 3 weeks [10].

References

Article

  1. Dixon JM. Breast infection. In: ABC of Breast Diseases, Dixon JM (Ed), Blackwell Publishing, Oxford 2006. p.19.
  2. Yanik B, Conkbayir I, Oner O, Hekimoğlu B. Imaging findings in Mondor's disease. J Clin Ultrasound 2003; 31:103.
  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.
  4. Tuli R, O'Hara BJ, Hines J, Rosenberg AL. Idiopathic granulomatous mastitis masquerading as carcinoma of the breast: a case report and review of the literature. Int Semin Surg Oncol 2007; 4:21.
  5. Aldaqal SM. Idiopathic granulomatous mastitis. Clinical presentation, radiological features and treatment. Saudi Med J 2004; 25:1884.
  6. Mansel R, Webster D, Sweetland H. The duct ectasia/periductal mastitis complex. In: Hughes Mansel & Webster's Benign Disorders and Diseases of the Breast, 3rd edition, Mnansel R, Webster D, Sweetland H (Eds), Saunders, China 2009. p.163.
  7. Dixon JM, Bundred NJ. Management of disorders of the ductal system and infections. In: Diseases of the Breast, Harris JR, Lippman ME, Morrow M, Osborne CK (Eds), Lippincott Williams & Wilkins, Philadelphia 2004. p.47.
  8. Mistiaen P, Poot E, Hickox S, et al. Preventing and treating intertrigo in the large skin folds of adults: a literature overview. Dermatol Nurs 2004; 16:43.
  9. Dixon JM. Benign breast disease. In: The New Airds Companion to Surgical Studies, Burnand KG, Young AE (Eds), Churchill Livingstone, Edinburgh 1992. p.811.
  10. Akbulut S, Arikanoglu Z, Senol A, et al. Is methotrexate an acceptable treatment in the management of idiopathic granulomatous mastitis? Arch Gynecol Obstet 2011; 284:1189.

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Last updated: 2019-07-11 22:49