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Mastitis

SURENDRA SINGH, 318

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Mastitis

An acute inflammation of the interlobular

connective tissue within the mammary gland

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Normal breast

architecture

Mastitis

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Outline

Epidemiology

Presentation

Predisposing factors Microbiology

Treatment

Complications Effect on breast milk

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Epidemiology

Incidence 2-33% ACOG reports 1-2% in U.S.

Most common worldwide

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Presentation

Systemic illness: Chills, myalgias

Fever of 38.5

Tender, hot, swollen wedge-shapederythematous area of breast

Usually one breast

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Differential Diagnosis

Fullness: bilateral, hot, heavy, hard, noredness

Engorgement: bilateral, tender, +/- fever,

minimal diffuse erythema Blocked Duct: painful lump with overlying

erythema, no fever, feel well, particulate

matter in milk

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Differential 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

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Causes

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

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Causes

3 groups Milk stasis (bacteria10^6)

Randomized treatment No intervention

Systematic emptying of breast Infectious group with 3rd intervention: antibiotics(PCN, Amp, Erythro) and systematic emptying

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Causes

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 betweenthe groups without lab data.

Conclusion: Treat with antibiotics

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Predisposing 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

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Predisposing factors

Damaged nipple (nipple fissure) Primiparity

Previous history of mastitis

Maternal or neonatal illness

Maternal stress

Work outside the home

Trauma

Genetic

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Microbiology

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

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Microbiology

Staph Aureus

Coag neg staph

Also, Group A and B hemolytic Strep, EColi, H. flu

MRSA

Fungal infections TB where endemic 1% of cases

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Fungal infections

Based on case reports that anti-fungal creamimproves 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

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Candida Infection

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Treatment

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

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Treatment

(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

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Treatment

(Alternative)

Therapeutic U/S

Accupunture

Bella donna, Phytolacca, Chamomilla,sulphur, Bellis perenis

Cabbage leaves

Avoid drinks like coffee withmethylxanthines, decreasing fat intake

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Complications

(Other bad things related to

mastitis)

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Breast Abscess

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Breast

abscess with

early skin

necrosis

Breast Abscess

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Abscess

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 independentvariable favoring abscess development

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Inflammatory

breast cancer

Breast Abscess

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Other Complications

Distortion of breast

Chronic inflammatio

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Granulomatous Mastitis

Noncaseating granulomas in a lobulardistribution

Differential Diagnosis TB mastitis

Foreign body Fat necrosis

Autoimmune: sarcoid, erythema nodusum,polyarthritis

Presentation Unilateral Breast lump No infection identified at presentation

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Granulomatous 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

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Neonatal Mastitis

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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 Mastitis

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Effect on Milk

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Immune 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

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Increased 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

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Mastitis