Mastitis

Mastitis

Wirsma Arif Harahap Surgical Oncologist Surgery Department

Mastitis

An acute inflammation of the

interlobular connective tissue within the mammary gland

Objective

Epidemiology

• Incidence 2-33%.

– Most common worldwide <10%

• Most common 2nd-3rd week postpartum

– 74-95% in first 12 weeks

– Can occur anytime in lactation

WHO 2000

Presentation

• Systemic illness: Chills, myalgias • Fever of ≥ 38.5 0C

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

Differential

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

• Galactocele: smooth rounded swelling (cyst)

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

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

Causes

• Milk Stasis

– Stagnant milk increases pressure in breast leading to leakage in surrounding breast tissue

– Milk, itself, causes an inflammatory response

• +/- Infection

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

Predisposing factors

• Damaged nipple (nipple fissure) • Primiparity

• Previous history of mastitis • Maternal or neonatal illness • Maternal stress

• Work outside the home • Trauma

Flat or Inverted

Nipples

• Begin treatment late in pregnancy

– Stop if causes uterine contractions

• Breast shells

– Wear 1 hour a day and gradually increase to several hours

– Dry area under nipple often

Offering Your Breast

to Baby

• Fingers underneath, thumb on top of breast • Fingers well behind

areola

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

Microbiology

• Staph Aureus

• Coag neg staph

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

• MRSA

• Fungal infections

Fungal 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

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 sx after 12-24 hours of milk removal

Treatment

• 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

Abscess

• Most common in first 6 weeks • 5-11% of mastitis cases

• Affect future lactation in 10% of affected ♀

• Treatment: I & D, U/S guided needle drainage

Complications

(Other bad things related to mastitis)

Other Complications

• Distortion of breast • Chronic inflammation

Granulomatous

Mastitis

• Noncaseating granulomas in a lobular distribution • Differential Diagnosis

– TB mastitis – Foreign body – Fat necrosis

– Autoimmune: sarcoid, erythema nodusum, polyarthritis

• Presentation

– Unilateral Breast lump

Granulomatous

Mastitis

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

• Diagnosis: Histology • Treatment:

– Antibiotics not helpful – Corticosteroids

– Excision biopsy

Subclinical Mastitis

• No symptoms, usually unilateral • Reduction in milk output

• Diagnosis: Increased milk sodium • Causes

– Milk stasis, poor nutrition, +/- bacteria

• Public Health implication

– Poor infant growth

– Increased risk of HIV transmission

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

Increased HIV

transmission risk

• Milk VL increases 10-20 fold

• 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 • Subclinical mastitis: Problem -Lab dxs only

Breast Cancer in

Pregnancy

Therapy

• 1st trimester : Operative.

Chemotherapy in 2nd trimester

• 2nd & 3rd trimester : Operative +

Chemotherapy Radiotherapy : after delivery.

Take Home

• Mastitis can decrease motivation to

breast feed