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.

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

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  2. 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. 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.
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  15. 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.
  16. 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.
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  18. 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.
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  30. 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.