Sandbox: Breast Abscess

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Ahmed Elsaiey, MBBCH [2]

Synonyms and keywords: Mammary abscess, Zuska's disease, lactiferous fistula.

Classification

Breast Abscess may be classified according to anatomical location and lactation state of the patient into subtypes.

• Anatomical location: subcutaneous, subareolar, interlobular, central and retromammary
• Lactation state: Lactational and Non-Lactational.

Pathophysiology

Following untreated mastitis, breast abscess could occur. Breast abscess is usually caused by staphylococcus aureus bacterial infection to an injured breast skin. Staphylococcus aureus could form abscess by secretion of several killing agents like enzymes and toxins. In a reaction to these bacterial substances, assembled white blood cells in this tissue produces anti-bacterial anti-bodies that help in killing the bacteria. However, these cells cause damage to the soft tissue contributing in the abscess formation. As the breast abscess is the complicated form of mastitis, the pathophysiology is mostly like the mastitis pathophysiology.

Pathogenesis

Breast abscess is the result of underlying inflammation (mastitis) in the breast skin. Injury may happen either during the lactation process from the infant or in the non-lactaion state of the patient as a cracking in the breast skin. This injury accelerates the entry of the causative bacteria which by its role form the abscess.
In neglected cases, there may be necrosis in the abscess location leads to fibrosis, scarring and nipple retraction.

• Lactational:
  • Injured breast skin allows the entrance of the bacteria to the mammillary ducts. This bacteria can be from the infant or the mother herself. Overproduction of the breast milk with no flow to the infant forms an opportunistic field for the bacteria to cause infection.
  • Breast Duct Ectasia: metaplastic change of the duct cells can cause duct ectasia. This change causes widening of the ducts lining which leads to thickening of the ducts and obstruction. The ducts become filled with fluid which leads to nipple discharge and infection by the entrance of the bacteria and can form pus and abscess as a final result.

• Non-Lactional:
  • Non lactational breast abscess is less common than lactational form. It can be subgrouped into central, peripheral and skin associating.
  • Cracking in the skin will overtly help the bacteria to enter and form the abscess.

Associated Diseases

More common in patients of diabetes mellitus.

Causes

Breast abscess is a bacterial infectious disease that is caused by many bacterial pathogens and it may also be caused by fungi mostly common candida through the infant mouth. It is almost caused by the same pathogens causing mastitis. To understand the common species causing breast abscess we can classify them into gram +ve and gram -ve bacteria.

Bacterial pathogens causing breast abscess

Gram +ve

Gram -ve

Staphylococcus Aureus (Most common cause of the lactational abscess) •MRSA (Became a common pathogen causing the abscess) •Coagulase -ve Staphylococcus Aureus

Streptococcus pyogens

Lactobacillus

Clostridium

Veillonella

Bacteroids

Escherishia Coli

Enterobacteria

Differentiating Breast abscess from other Diseases

Breast abscess should be differentiated from other diseases that cause swelling in the breast skin. These diseases are like breast mass, mastitis, galactocele, plugged duct and Mondor's syndrome.

Diseases	Laboratory Findings				Physical Examination				History and Symptoms								Other Findings
	CBC	Culture	Biopsy	Lab Test 4	Mass	Breast tenderness	Physical Finding 3	Physical Finding 4	History of trauma	Nipple retraction	Nipple discharge	Erythema	Fever	Warmth	Lymphadenopathy	Itching
Mastitis	✘	+ Bacterial culture	✘		✔	✔			✔	✘	✘	✔	✔	✔	✔	✘
Inflammatory breast cancer			✔		✔	✔			✘	✔	✘	✔	✘	✔	✔	✔	*Peau d'orange apperance. *Metastasis is common
Galactocele		↓
Plugged duct
Mondor's syndrome
Cellulitis
Fibroadenoma
Lipoma

Epidemiology and Demographics

Breast abscess is a rare disease that may occur due to improper treatment of the mastitis. There is no significant prevalence concerning the abscess.

Incidence

• The incidence of breast abscess is 3,000-11,000 per 100,000 of patients with mastitis.
• The incidence of breast abscess is only 100-3,000 per 100,000 of the puerperal patients.

Age

• Patients of all age groups may develop breast abscess.
• Breast abscess is more common observed in the infants and the young more than the elder.
• It is common in neonates with mastitis as approximately 50 percent of the neonatal patients with mastitis can develop breast abscess.

Gender

Breast abscess occurs commonly in women. It is very rare to be developed in men.

Race

Breast abscess is more prevalent in the african american race.

Risk Factors

More common risk factors

• The most important risk factor of breast abscess is trauma.Trauma increases the possibility of the abscess formation as it facilitates the entrance of the causative bacteria into the soft tissue. Trauma can take place by different ways like shaving subareolar hair, piercing of nipple, infant's mouth during breastfeeding and picking acne lesions.
• Smoking: increases the chances of abscess recurrence.
• Obesity
• Diabetes mellitus
• Duct ectasia of the breast.
• Local skin infection

Less common risk factors

These risk factors are related more to the non-lactational breast abscess.

• Insect bites
• Increasing age
• Surgical treatment: increases recurrence rate of the abscess.

Natural history, complications and prognosis

Inflammatory breast cancer complication

Diagnosis

History and Symptoms

Breast abscess can be noticed first by the patient like a breast mass or lump. The patient usually has current breast infection(mastitis) or history of the infection. In order to get precise diagnosis of breast abscess, these items should be put in consideration:

• Local painful breast lump
• History of mastitis
• Nipple discharge
• Risk factors of the breast abscess like trauma, duct ectasia or insect bites.
• If lactating patient: breast-feeding history
• If non-lactating history: diabetic history

Most common symptoms

Breast abscess has a typical abscess symptoms which are:

• Fever and fatigue
• Redness
• Warmth
• localized swelling
• Breast skin induration

Less common symptoms

• Nipple discharge
• Fistula
• Mass in the breast

Physical examination

Patients with breast abscess are remarkable for the breast tenderness, swelling, redness and warmth of the skin.

Laboratory findings

Breast abscess diagnosis depends only on the clinical manifestations of the abscess not the laboratory findings. However, a culture could be taken from the milk and the pus just to decide the antibiotics needed for the treatment.

Electrocardiogram

There is no significant changes in the EKG of breast abscess patients.

Chest X ray

There is no x-ray changes in the chest of breast abscess patients.

CT Scan

CT scan is not used to diagnose the breast abscess. However, it can be performed to exclude other diseases like breast cancer.

Ultrasound

• Ultrasonography is an important imaging approach for diagnosis of the breast abscess. It is mainly used to differentiate between the different diseases causing breast lumps. It is also used in abscess needle aspiration guiding.
• Breast abscess on chest ultrasonography appears like medium sized collections with not well defined margins and may have some areas with increased density.
• There is no vascularity in the US image.

Other Imaging Findings

Mammography is not indicated to be used in diagnosis of the breast abscess. However, it is strongly recommended in these cases to be used to differentiate between the breast abscess and other breast diseases and cancer.