A 26-year-old woman who is 5 weeks post partum presents with right breast pain and a fever. She is breast-feeding her son. Over the last 3 weeks she has seen her general practitioner (GP) on two occasions with mastitis and has been prescribed antibiotics. However,the pain is now worsening and she is starting to feel more unwell. She is normally fit and
healthy. She does not take any regular medications and is allergic to penicillin.
She has a temperature of 37.9°C and a pulse rate of 92/min. On examination, there is a localized, tender area, adjacent to the areola of the right breast. There is surrounding erythema and tender lymphadenopathy in the right axilla.
Breast and endocrine
• What is the likely diagnosis?
• What other investigations would you arrange?
• What are the treatment options, and what other considerations do you have to
make when prescribing?
• What other advice would you give regarding her breast-feeding?
This woman has a puerperal breast abscess. Mastitis occurs frequently in lactating females. Infection is most common in the first 6 weeks post partum. This is the result of organisms entering through traumatized skin and cracked nipples. It is usually treated with antibiotics, and mothers are advised to continue expressing from the breast to aid drainage through the ducts. Occasionally the infection can progress and lead to a breast abscess. The most commonly involved organisms are Staphylococcus aureus and the Streptococcus species.
Non-lactating breast abscesses occur most commonly around the age of 30 years and are often associated with duct ectasia. Periareolar abscesses are found to be associated with smoking, whereas peripheral abscesses are more common in immunosuppressed women,such as those taking steroids or patients with diabetes.
In this case other investigations would include anaerobic and aerobic cultures taken from the abscess. These can usually be obtained by needle aspiration under ultrasound guidance.
Treatment is either by recurrent needle aspiration or by incision and drainage. Antibiotics should be continued. Flucloxacillin (or erythromycin if the patient is penicillin allergic) are recommended, but the choice of antibiotic should be guided by the culture results.
Co-amoxiclav is prescribed in non-lactating breast abscesses where anaerobes and enterococci may also be causative. Appropriate analgesia should also be prescribed. It is imperative to remember that this patient is breast-feeding and the British National
Formulary (BNF – Appendix 4) should be consulted before prescribing to ensure there are no contraindications.
• It is important to note that if the inflammation or mass persists after treatment, then the possibility of breast cancer should be ruled out with further imaging and tissue sampling.