Mastitis And Breast Abscess

Question 1

Mastitis Definition

Answer 1

Inflammation of the breast tissue, with or without infection.
Most common in lactating women (lactational or puerperal mastitis) but can also occur in the absence of lactation (non-lactational mastitis).
Most common occurs two to three weeks following delivery

Question 2

Lactational Mastitis: Epidemiology and Risk factors

Answer 2

Milk stasis, which may be caused by:
- Poor infant attachment to breast e.g. due to tongue-tie
- Reduced number of feeds: e.g. due to partial bottle-feeding, breast pain, weaning
- Pressure on breast e.g. from bras, tight clothing, prone sleeping position
Aged 21-35 years
Smoking
Previous mastitis

Question 3

Non-Lactational Mastitis: Epidemiology and Risk factors

Answer 3

• Smoking
• Nipple damage, e.g. from piercings and skin conditions such as eczema
• Underlying breast abnormality
• Immunosuppression
• Hair removal from the areola
• Breast implants

Question 4

Granulomatous mastitis

Answer 4

• Rarer inflammatory condition
• Thought autoimmune in nature
• The clinical features can mimic those breast cancer and biopsy is needed to differentiate the two.

Question 5

Breast abscess

Answer 5

Localised collection of pus = complication of mastitis
An abscess can also occur without any apparent preceding mastitis

Question 6

Lactational mastitis aetiology

Answer 6

Milk stasis = MC underlying cause
Milk is effectively removed from the breast during breastfeeding, the accumulated milk can lead to an inflammatory response.
This can progress to infection if bacteria enter the breast (usually through a traumatised nipple)
Staphylococcus aureus MC common infective organism.

Question 7

Non-lactational mastitis aetiology

Answer 7

Assosciated with infection = central or peripheral
- Central/subareolar infection: usually caused by periductal mastitis or duct ectasia
- Peripheral infection: less common, may be assosciated with underlying conditions such as diabetes and rheumatoid arthritis.

Question 8

Signs

Answer 8

• Breast swelling, tenderness and redness: typically in a wedge-shaped distribution
• Visible nipple fissure
• Purlent nipple discharge
• Breast abscess: painful, swollen lump in breast with overlying erythema

Question 9

Symptoms

Answer 9

Breast pain: usually unilateral and in a defined area
Fever
Flu-like symptoms

Question 10

Diagnosis

Answer 10

Clinical diagnosis
Consider:
- Breast milk culture: considered in recurrent, severe, or atypical infections or if a hospital-acquired infection is suspected
- Breast ultrasound: used to confirm the diagnosis if breast abscess is suspected.

Question 11

Management lactational mastitis

Answer 11

Lactational mastitis:
- Effective milk removal
= encourage ongoing breastfeeding
= apply a warm compress to the breast before feeding and massage lumpy area
= express after feeds if needed
Abx: infected nipple fissure 12-24 hours of effective milk removal, or if a breast milk culture is positive
Flucloxacillin = FIRST-LINE
Admission and referral: may be needed if sepsis, breast abscess or breast cancer is suspected.

Question 12

Management non-lactational mastitis

Answer 12

Abx: Co-amoxiclav = FIRST LINE
Analgesia
Hot compresses
Admission and referral: may be needed if sepsis, breast abscess or breast cancer suspected

Question 13

Breast abscess

Answer 13

Refer urgently to surgeons: for confirmation of diagnosis by USS + drainage of the abscess (by ultrasound-guided aspiration or incision and drainage)

Question 14

Complications

Answer 14

Treatment failure and recurrence
Cessation of breastfeeding: abruptly stopping breastfeeding in mastitis increases the risk of abscess formation - It may also lead to emotional distress in women who have otherwise planned to continue
Breast abscess: around 3% of women with mastitis go on to develop breast abscess
Sepsis: immunocompromised patients are at higher risk.