Sandbox: Breast Abscess
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.
Overview
Historic Perspective
Classification
Breast Abscess may be classified according to anatomical location and lactation state of the patient into subtypes.[1]
- 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.[2]
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. [3]
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.[4]
- 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. [5]
- 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.
Gross Pathology
Microscopic Pathology
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. [6][7][8]
| 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 mastitis, inflammatory breast cancer, galactocele, plugged duct, Mondor's syndrome, fibroadenoma and lipoma.[9][10] [11][12][13][14][15][16][17][18]
| Diseases | Laboratory Findings | Physical Examination | History and Symptoms | Other Findings | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Breast milk and pus culture | Biopsy | Breast tenderness | Skin induration | Cordlike vein appearance | History of trauma | Nipple retraction | Nipple discharge | Erythema | Fever | Warmth | Lymphadenopathy | Itching | ||
| Breast abscess | + | ✘ | ✔ | ✔ | ✘ | ✔ | ✘ | ✔ | ✔ | ✔ | ✔ | ✘ | ✘ | |
| Mastitis | + | ✘ | ✔ | ✘ | ✔ | ✘ | ✔ | ✔ | ✔ | ✔ | ✔ | ✘ | ||
| Inflammatory breast cancer | ✘ | ✔ | ✔ | ✔ | ✘ | ✔ | ✘ | ✔ | ✘ | ✔ | ✔ | ✔ | *Peau d' orange appearance of the skin
*Metastasis is common. | |
| Galactocele | ✘ | ✘ | ✘ | ✘ | ✘ | ✘ | ✔ | ✘ | ✘ | ✘ | ✘ | ✘ | It is differentiated from other masses by US. | |
| Plugged duct | ✘ | ✘ | ✔ | ✘ | ✘ | ✘ | ✘ | ✘ | ✘ | ✘ | ✘ | ✘ | ||
| Mondor's syndrome | ✔ | ✔ | ✔ | ✘ | Retracted breast skin and elevation of the skin may be observed. | |||||||||
| Cellulitis | ✘ | ✔ | ✔ | ✔ | ✘ | ✔ | ✔ | ✘ | ||||||
| Fibroadenoma | ✘ | ✔ | ✘ | ✘ | ✘ | ✘ | ✔ | *Peau d' orange skin apperance.
*Enlarged veins on the skin | ||||||
Other differential diagnosis of breast abscess can include: cystosarcoma phyllodes, breast cyst, breast carcinoma, lymphangioma, hemangioma and 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. [19][20]
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.[7]
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.[21]
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.[22]
- 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.[23]
- Insect bites
- Increasing age
- Surgical treatment: increases recurrence rate of the abscess.[22]
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:[10] [11]
- 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[24]
- 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.[25]
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.[26]
- Breast abscess on chest ultrasonography appears like medium sized collections with not well defined margins and may have some areas with increased density.[27]
- 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.[28]
Treatment
Breast abscess treatment regimen includes both abscess drainage (surgically and by aspiration) and antibiotic medical therapy.The patient should be referred immediately to the breast surgeon to start the abscess drainage.[3]
Medical therapy
Breast abscess is treated with antibiotic medical therapy alongside abscess drainage and suction. The choice of the antibiotic medications depends on the pathogen type however, the high possibility of the pathogen to be staphylococcus aureus leads to start the antibiotic medications before the result of the discharge culture.[29].
General measures
Breast abscess is painful so providing analgesics like the profen is indicated to the patients. In order to relieve the pain and decrease the edema, breast support is indicated also.[3]
Lactaitonal breast abscess
- Flucloxacillin 500 mg BID if there is no allergy to penicillin.
- Dicloxacillin 500 mg PID if there is no allergy to penicillin.
- Erythromycin 500 mg BID in case of penicillin allergy.
Non lactational breast abscess
- Co-amocyclave 375 TID if there is no allegy to penicillin.
- Combination of Erythtomycin 500 mg BID and Metronidazole 200 mg TID in case of penicillin allergy.
Surgery
The best line of breast abscess treatment is US guided needle aspiration and surgical drainage of the abscess.[30]
Aspiration
US guided needle aspiration is a good line of treatment of the breast abscess. It is used particularly in the small and medium sized abscesses. Local anaesthesia is required in order to reduce the pain of the abscess location.
References
- ↑ Dixon JM (1994). "ABC of breast diseases. Breast infection". BMJ. 309 (6959): 946–9. PMC 2541130. PMID 7755694.
- ↑ Kobayashi SD, Malachowa N, DeLeo FR (2015). "Pathogenesis of Staphylococcus aureus abscesses". Am J Pathol. 185 (6): 1518–27. doi:10.1016/j.ajpath.2014.11.030. PMC 4450319. PMID 25749135.
- ↑ 3.0 3.1 3.2 Kataria K, Srivastava A, Dhar A (2013). "Management of lactational mastitis and breast abscesses: review of current knowledge and practice". Indian J Surg. 75 (6): 430–5. doi:10.1007/s12262-012-0776-1. PMC 3900741. PMID 24465097.
- ↑ Marchant DJ (2002). "Inflammation of the breast". Obstet Gynecol Clin North Am. 29 (1): 89–102. PMID 11892876.
- ↑ Bundred NJ, Dixon JM, Lumsden AB, Radford D, Hood J, Miles RS; et al. (1985). "Are the lesions of duct ectasia sterile?". Br J Surg. 72 (10): 844–5. PMID 4041720.
- ↑ Dabbas N, Chand M, Pallett A, Royle GT, Sainsbury R (2010). "Have the organisms that cause breast abscess changed with time?--Implications for appropriate antibiotic usage in primary and secondary care". Breast J. 16 (4): 412–5. doi:10.1111/j.1524-4741.2010.00923.x. PMID 20443790.
- ↑ 7.0 7.1 Kaneda HJ, Mack J, Kasales CJ, Schetter S (2013). "Pediatric and adolescent breast masses: a review of pathophysiology, imaging, diagnosis, and treatment". AJR Am J Roentgenol. 200 (2): W204–12. doi:10.2214/AJR.12.9560. PMID 23345385.
- ↑ Surani S, Chandna H, Weinstein RA (1993). "Breast abscess: coagulase-negative staphylococcus as a sole pathogen". Clin Infect Dis. 17 (4): 701–4. PMID 8268353.
- ↑ Greydanus DE, Matytsina L, Gains M (2006). "Breast disorders in children and adolescents". Prim Care. 33 (2): 455–502. doi:10.1016/j.pop.2006.02.002. PMID 16713771.
- ↑ 10.0 10.1 Jahanfar S, Ng CJ, Teng CL (2013). "Antibiotics for mastitis in breastfeeding women". Cochrane Database Syst Rev (2): CD005458. doi:10.1002/14651858.CD005458.pub3. PMID 23450563.
- ↑ 11.0 11.1 Lam E, Chan T, Wiseman SM (2014). "Breast abscess: evidence based management recommendations". Expert Rev Anti Infect Ther. 12 (7): 753–62. doi:10.1586/14787210.2014.913982. PMID 24791941.
- ↑ Kleer CG, van Golen KL, Merajver SD (2000). "Molecular biology of breast cancer metastasis. Inflammatory breast cancer: clinical syndrome and molecular determinants". Breast Cancer Res. 2 (6): 423–9. doi:10.1186/bcr89. PMC 138665. PMID 11250736.
- ↑ Dawood S, Merajver SD, Viens P, Vermeulen PB, Swain SM, Buchholz TA; et al. (2011). "International expert panel on inflammatory breast cancer: consensus statement for standardized diagnosis and treatment". Ann Oncol. 22 (3): 515–23. doi:10.1093/annonc/mdq345. PMC 3105293. PMID 20603440.
- ↑ Jaiyesimi IA, Buzdar AU, Hortobagyi G (1992). "Inflammatory breast cancer: a review". J Clin Oncol. 10 (6): 1014–24. doi:10.1200/JCO.1992.10.6.1014. PMID 1588366.
- ↑ Indelicato DJ, Grobmyer SR, Newlin H, Morris CG, Haigh LS, Copeland EM; et al. (2006). "Delayed breast cellulitis: an evolving complication of breast conservation". Int J Radiat Oncol Biol Phys. 66 (5): 1339–46. doi:10.1016/j.ijrobp.2006.07.1388. PMID 17126205.
- ↑ Belleflamme M, Penaloza A, Thoma M, Hainaut P, Thys F (2012). "Mondor disease: a case report in ED". Am J Emerg Med. 30 (7): 1325.e1–3. doi:10.1016/j.ajem.2011.06.031. PMID 21855258.
- ↑ Shetty MK, Watson AB (2001). "Mondor's disease of the breast: sonographic and mammographic findings". AJR Am J Roentgenol. 177 (4): 893–6. doi:10.2214/ajr.177.4.1770893. PMID 11566698.
- ↑ Kadioglu H, Yildiz S, Ersoy YE, Yücel S, Müslümanoğlu M (2013). "An unusual case caused by a common reason: Mondor's disease by oral contraceptives". Int J Surg Case Rep. 4 (10): 855–7. doi:10.1016/j.ijscr.2013.07.026. PMC 3785854. PMID 23959419.
- ↑ Amir LH, Forster D, McLachlan H, Lumley J (2004). "Incidence of breast abscess in lactating women: report from an Australian cohort". BJOG. 111 (12): 1378–81. PMID 15663122.
- ↑ Whitaker-Worth DL, Carlone V, Susser WS, Phelan N, Grant-Kels JM (2000). "Dermatologic diseases of the breast and nipple". J Am Acad Dermatol. 43 (5 Pt 1): 733–51, quiz 752-4. doi:10.1067/mjd.2000.109303. PMID 11050577.
- ↑ Bharat A, Gao F, Aft RL, Gillanders WE, Eberlein TJ, Margenthaler JA (2009). "Predictors of primary breast abscesses and recurrence". World J Surg. 33 (12): 2582–6. doi:10.1007/s00268-009-0170-8. PMC 3892669. PMID 19669231.
- ↑ 22.0 22.1 Gollapalli V, Liao J, Dudakovic A, Sugg SL, Scott-Conner CE, Weigel RJ (2010). "Risk factors for development and recurrence of primary breast abscesses". J Am Coll Surg. 211 (1): 41–8. doi:10.1016/j.jamcollsurg.2010.04.007. PMID 20610247.
- ↑ Benson EA (1989). "Management of breast abscesses". World J Surg. 13 (6): 753–6. PMID 2696229.
- ↑ Faden H (2005). "Mastitis in children from birth to 17 years". Pediatr Infect Dis J. 24 (12): 1113. PMID 16371879.
- ↑ Spencer JP (2008). "Management of mastitis in breastfeeding women". Am Fam Physician. 78 (6): 727–31. PMID 18819238.
- ↑ Muttarak M, Chaiwun B (2004). "Imaging of giant breast masses with pathological correlation". Singapore Med J. 45 (3): 132–9. PMID 15029418.
- ↑ Fahrni M, Schwarz EI, Stadlmann S, Singer G, Hauser N, Kubik-Huch RA (2012). "Breast Abscesses: Diagnosis, Treatment and Outcome". Breast Care (Basel). 7 (1): 32–38. doi:10.1159/000336547. PMC 3335354. PMID 22553470.
- ↑ Kerlikowske K, Smith-Bindman R, Ljung BM, Grady D (2003). "Evaluation of abnormal mammography results and palpable breast abnormalities". Ann Intern Med. 139 (4): 274–84. PMID 12965983.
- ↑ Dixon JM (2007). "Breast abscess". Br J Hosp Med (Lond). 68 (6): 315–20. doi:10.12968/hmed.2007.68.6.23574. PMID 17639835.
- ↑ Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJ, Gorbach SL; et al. (2014). "Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of America". Clin Infect Dis. 59 (2): 147–59. doi:10.1093/cid/ciu296. PMID 24947530.