BREAST ABSCESS

BREAST ABSCESS - Anya S. Koutras, MD; Kristen Burdick, MD
BASICS
DESCRIPTION
• Collection of pus, usually localized.
• Can be associated with lactation or fistulous tracts secondary to squamous epithelial neoplasm or duct occlusion
• System(s) Affected: Skin/Exocrine
• Synonym(s): Mammary abscess; Peripheral breast abscess; Subareolar abscess; Puerperal abscess
ALERT
Pregnancy Considerations
Most commonly associated with postpartum lactation
GENERAL PREVENTION
• Prevention of mastitis
• Early treatment of mastitis with milk expression and cold compresses
• Early treatment with antibiotics
EPIDEMIOLOGY
• Predominant age
- Puerperal abscess: Premenopausal
- Subareolar abscess: Postmenopausal
• Predominant sex: Female
Incidence
• 0.1-0.5% of breast-feeding women
• Puerperal abscess rare after 1st 6 weeks of lactation
RISK FACTORS
• Puerperal mastitis: 5-11% go on to abscess (most often due to inadequate therapy). Risk factors for mastitis are those that result in milk stasis (infrequent feeds, missing feeds)
• Poor latch, damaged nipple, illness in mother or baby, rapid weaning, breast pressure, blocked nipple pore or duct, maternal stress or fatigue, maternal malnutrition
• General factors: Diabetes, rheumatoid arthritis,
• Steroids, silicone/paraffin implants, lumpectomy with radiation, heavy cigarette smoking,
• Nipple retraction
ETIOLOGY
• Delayed treatment of mastitis
• Puerperal abscesses: Blocked lactiferous duct
• Subareolar abscess: Squamous epithelial neoplasm with keratin plugs or ductal extension with associated inflammation
• Peripheral abscess: Stasis of the duct


DIAGNOSIS
SIGNS AND SYMPTOMS
• Tender breast lump, fluctuant, usually unilateral
• Erythema
• Draining pus
• Local edema
• Systemic malaise (though usually less malaise than with mastitis)
• Fever
• Nipple and skin retraction
• Proximal lymphadenopathy
TESTS
Lab
• Leukocytosis
• Elevated sedimentation rate
• Culture and sensitivity of drainage to identify pathogen, usually Staphylococci or Streptococci. E. coli is 3rd most common. Nonlactational abscess associated with anaerobic bacteria.
Imaging
• Ultrasound
• Mammogram
Diagnostic Procedures/Surgery
• Aspiration for culture
• Fine-needle aspiration not accurate to exclude carcinoma
Pathological Findings
• Squamous metaplasia of the ducts
• Intraductal hyperplasia
• Epithelial overgrowth
• Fat necrosis
• Duct ectasia
DIFFERENTIAL DIAGNOSIS
• Carcinoma (inflammatory or primary squamous cell))
• Tuberculosis (may be associated with HIV infection)
• Actinomycosis
• Typhoid
• Sarcoid
• Granulomatous disease
• Syphilis
• Foreign body reactions (e.g., to silicone and paraffin)
• Mammary duct ectasia
• Hydatid cyst
• Sebaceous cyst
TREATMENT
PRE-HOSPITAL
Outpatient, unless systemically immunocompromised or septic
GENERAL MEASURES
• Cold compresses for pain control
• Important to continue to breast-feed or express milk
Diet
• No restrictions
• Lecithin supplementation
Activity
No restrictions
MEDICATION (DRUGS)
• Must combine antibiotics with drainage for cure
• Culture mid-stream sample of milk for mastitis, abscess fluid for breast abscess.
• NSAIDs
• Start with dicloxacillin 500 mg q.i.d. for 10-14 days
• If no response in 24-48 hours, switch to:
• Cephalexin 500 mg q.i.d. for 10-14 days
- Or amoxicillin-clavulanate (Augmentin) 250 mg t.i.d.
• Clindamycin 300 mg t.i.d. if anaerobes suspected
• Contraindications: Allergy to the antibiotic
• Precautions: Refer to manufacturer's profile for each drug
• Significant possible interactions: Refer to manufacturer's profile for each drug
SURGERY
• Aspiration under ultrasound guidance (1,2)[B], (3)[C]
• If aspiration and antibiotics fail, incision and drainage with removal of loculations
• Biopsy of all nonpuerperal abscesses to rule out carcinoma
• Open all fistulous tracts, especially in nonlactating abscesses
FOLLOW-UP
PROGNOSIS
• Good. Complete healing expected in 8-10 days
• Subareolar abscess frequently reoccur, even after I+D and antibiotics; may require surgical removal of ducts.
COMPLICATIONS
Fistula
PATIENT MONITORING
Ensure resolution to exclude carcinoma.
REFERENCES
1. Dener C, Inan A. Breast abscesses in lactating women. World J Surgery. 2003;27:130.
2. Schwarz, RJ, Shrestha R. Needle aspiration of breast abscesses. Am J Surgery. 2001;182:117.
3. Christensen AF, Al-Suliman N, et al. Ultrasound-guided drainage of breast abscesses: Results in 151 patients. Br J Radiol. 2005 Mar; 78(927):186-188.
ADDITIONAL READING
• Cibele B, Schwartz K, Foxman B. Lactation mastitis. JAMA. 2003;289:1609-1612.
• Ng C, Jahanfar S, Teng CL. Antibiotics for mastitis in breastfeeding women (Protocol). Cochrane Database of Systematic Reviews, 2005;(3): CD005458.