MastitisMastitis

SURENDRA SINGH, 318SURENDRA SINGH, 318

MastitisMastitis

An acute inflammation of the interlobular An acute inflammation of the interlobular connective tissue within the mammary glandconnective tissue within the mammary gland

Normal breast architecture

MastitisMastitis

OutlineOutline

• Epidemiology

• Presentation

• Predisposing factors

• Microbiology

• Treatment

• Complications

• Effect on breast milk

EpidemiologyEpidemiology

• Incidence 2-33%– ACOG reports 1-2% in U.S.– Most common worldwide <10%

• Most common 2nd-3rd week postpartum– 74-95% in first 12 weeks– Can occur anytime in lactation

PresentationPresentation

• Systemic illness: Chills, myalgias

• Fever of ≥ 38.5

• Tender, hot, swollen wedge-shaped erythematous area of breast

• Usually one breast

Differential DiagnosisDifferential Diagnosis

• Fullness: bilateral, hot, heavy, hard, no redness

• Engorgement: bilateral, tender, +/- fever, minimal diffuse erythema

• Blocked Duct: painful lump with overlying erythema, no fever, feel well, particulate matter in milk

Differential DiagnosisDifferential Diagnosis

• Galactocele: smooth rounded swelling (cyst)

• Abscess: tender hard breast mass, +/- fluctuance, skin erythema, induration, +/- fever

• Inflammatory Breast Carcinoma: unilateral, diffuse and recurrent, erythema, induration

CausesCauses

• Milk Stasis– Stagnant milk increases pressure in breast

leading to leakage in surrounding breast tissue

– Milk, itself, causes an inflammatory response

• +/- Infection– Milk provides medium for bacterial growth

CausesCauses

• 3 groups– Milk stasis (bacteria<10^3, leuk<10^6)– Noninfectious inflammation (bacteria <10^3, leuk

>10^6)– Infectious (bacteria >10^3, leuk>10^6)

• Randomized treatment – No intervention– Systematic emptying of breast– Infectious group with 3rd intervention: antibiotics

(PCN, Amp, Erythro) and systematic emptying

CausesCauses

• “Poor results”– Milk stasis (10) – 3 recurrences, 7 impaired

lactation– Noninfectious (20) – 13 recurrences– Infectious (76 – only 2 in Abx group) – 6

abscesses, 21 recurrences

• Could not clinically tell difference between the groups without lab data.

• Conclusion: Treat with antibiotics

Predisposing factorsPredisposing factors• Improper nursing technique

– Timing of feeds– Poor attachment

• Oversupply of milk– Overabundant milk supply– Lactating for multiples– Rapid weaning– Blocked nipple pore or duct

• Pressure on Breast– Tight Bra– Car seatbelt (yes, this is actually listed)– Prone sleeping position

Predisposing factorsPredisposing factors

• Damaged nipple (nipple fissure)• Primiparity• Previous history of mastitis• Maternal or neonatal illness• Maternal stress• Work outside the home• Trauma• Genetic

MicrobiologyMicrobiology

• Detection of pathogens difficult– Usually nasal/skin flora– Difficult to avoid contamination

• Milk culture– Encouraged in hospital acquired, recurrent

mastitis, or no response in 2 days

MicrobiologyMicrobiology

• Staph Aureus

• Coag neg staph

• Also, Group A and B βhemolytic Strep, E Coli, H. flu

• MRSA

• Fungal infections

• TB where endemic – 1% of cases

Fungal infectionsFungal infections

• Based on case reports that anti-fungal cream improves sx

• Case reports of cyptococcal infection• Most common: Candida Albicans

– Genital tract Newborn oral colonization

• May lead to nipple fissure• Thought to be associated with deep, shooting

pains and nipple discomfort• Most commonly treated with fluconozole to ♀,

oral nystatin to infant

Candida InfectionCandida Infection

TreatmentTreatment

• Supportive Therapy– Rest, fluids, pain medication, anti-inflammatory

agents, encouragement

• Continue breast feeding• Antibiotics that cover Staph and Strep

– Culture results– Severe symptoms– Nipple fissure– No improved after 12-24 hours of milk removal

TreatmentTreatment(ACOG)(ACOG)

• Dicloxicillin 500 mg qid

• Erythromycin if PCN allergic

• If resistant to treatment penicillinase-producing staph, then vancomycin or cefotetan until 2 days after infection subsides

• Minimum treatment 10-14 days

TreatmentTreatment(Alternative)(Alternative)

• Therapeutic U/S

• Accupunture

• Bella donna, Phytolacca, Chamomilla, sulphur, Bellis perenis

• Cabbage leaves

• Avoid drinks like coffee with methylxanthines, decreasing fat intake

ComplicationsComplications

(Other bad things related to (Other bad things related to mastitis)mastitis)

Breast AbscessBreast Abscess

Breast abscess with early skin necrosis

Breast AbscessBreast Abscess

AbscessAbscess

• Most common in first 6 weeks • 5-11% of mastitis cases• Affect future lactation in 10% of affected ♀• No differences b/t groups by age, parity,

localization of infection, cracked nipples, + milk cultures, mean lactation time

• Duration of symptoms: only independent variable favoring abscess development

Inflammatory breast cancer

Breast AbscessBreast Abscess

Other ComplicationsOther Complications

• Distortion of breast • Chronic inflammatio

Granulomatous MastitisGranulomatous Mastitis

• Noncaseating granulomas in a lobular distribution

• Differential Diagnosis– TB mastitis – Foreign body– Fat necrosis– Autoimmune: sarcoid, erythema nodusum,

polyarthritis• Presentation

– Unilateral Breast lump– No infection identified at presentation

Granulomatous MastitisGranulomatous Mastitis

• Can mimic Breast Ca on clinical, radiological, and cytological exams

• Diagnosis: Histology• Treatment:

– Antibiotics not helpful– Corticosteroids– Excision biopsy

• Limited literature, but no clear association with breast feeding, OCPs

Neonatal MastitisNeonatal Mastitis

• Occurs up to 5 weeks of age

• Girls outnumber boys 2 : 1

• Etiology: 85% S. aureus, also E. coli, group D Streptococcus

• Treatment:– Prompt antibiotics (IV?)– Careful needle aspiration if abscess

Neonatal MastitisNeonatal Mastitis

Effect on MilkEffect on Milk

Immune FactorsImmune Factors

• IgA is predominant in milk

• Increased immune factors from both plasma and local epithelial cells

• No adverse events documented in peds– Poor growth documented likely related to poor

milk production– Contradictory studies showing benefit or harm

• Interest in pediatric vaccine development

Michie 2003, Filteau 2003

Increased HIV transmission riskIncreased HIV transmission risk

• Alternating breast/bottle increased risk

• Role of free virus vs cell bound virus unclear

• If ♀ must breast feed, then pump on affected breast (pasteurize) and feed on unaffected

Michie 2003, Filteau 2003

MastitisMastitis