Breast Abscess

Question 1

What is a breast abscess?

Answer 1

Painful collection of pus that forms in the breast tissue.

Question 2

Who does it affect?

Answer 2

3% of women with mastitis go on to develop an abscess.
1 in 10 breastfeeding women affected.
African women.

Question 3

Causes of breast abscess:

Answer 3

• Bacterial: staphylococcus aureus.
• Infections can occur during breastfeeding if bacteria enter your breast tissue, or if the milk ducts become blocked.
• Non breastfeeding women - can develop mastitis if bacteria enter the milk ducts through a sore or cracked nipple.

Question 4

In non-lactating women, what is mastitis categorised as:

Answer 4

• Central/subareolar infection: infected lumps that occur just under the areola, the coloured skin around the nipple.
• peripheral non- lactating infection: has been associated with DM, rheumatoid arthritis, trauma, corticosteroid treatment, but often there is no underlying cause.

Question 5

Symptoms?

Answer 5

• History of recent mastitis
• Fever or general malaise
• Painful swollen lump in the breast, with redness, heat and swelling of the overlying skin.

Question 6

Risk factors

Answer 6

• Lactation
• Poor breast-feeding technique
• Smoking
• previous mastitis.
• Nipple piercing
• Immunosuppression
• Foreign body e.g. silicone implant.

Encourage: to empty milk from breast.

Question 7

Signs on examination:

Answer 7

• Swollen lump
• Redness
• high temperature
• Cause swelling of the surrounding skin.

Question 8

What investigations would you do?

Answer 8

• Blood test: (WBC - for infection)
• Culture of pus
• URGENT ULTRASOUND: will show whether there is collection of pus and should be considered when infection does not settle after one course of antibiotic.

Question 9

How would you explain the condition to the patient?

Answer 9

1) Bacteria enters through small cracks/breaks in skin
2) Overgrowth of usually harmless bacteria already in the milk duct (maybe due to stagnant milk in blocked duct)

Immune system tries to fight the bacteria by sending WBCs there. WBCs attack bacteria –> some normal breast tissue dies at site of infection –> small, hollow pocket formed –> fills with pus –> abscess

Question 10

How would you treat a breast abscess?

Answer 10

Antibiotic – non-lactating give co-amoxiclav, penicillin allergy give clarithromycin/erythromycin + metronidazole
- Lactating – culture breast milk and base antibiotic on that, if no culture treat empirically with flucloxacillin, erythromycin/clarithromycin for those allergic to penicillin

Drainage of abscess – needle and syringe for small ones, small incision for large ones (under local anaesthetic)

Symptomatic relief – analgesia, NSAID
Avoid nursing from affected breast
Express breast milk from affected breast

Question 11

Differential diagnosis:

Answer 11

Conditions that cause breast pain and are associated with lactation: Full breasts, engorged breasts, a blocked duct, galactocele (retention cyst containing milk or a milky substance) and infection of the mammary ducts.
Conditions that cause breast pain that are not associated with lactation include: Breast cancer, duct ectasia, cellulitis, fibroadenosis, ruptured breast cyst, necrotising fasciitis of the breast, fat necrosis of the breast.
Conditions that cause nipple pain include: Poor infant attachment, candida infection of the nipple, blanching of the nipple, bacterial infection of the nipple, Raynaud’s disease of the nipple.