Mastitis
SURENDRA SINGH, 318
Mastitis
An acute inflammation of the interlobular
connective tissue within the mammary gland
Mastitis
Normal breast
architecture
Outline
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Epidemiology
Presentation
Predisposing factors
Microbiology
Treatment
Complications
Effect on breast milk
Epidemiology
• 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
Presentation
• Systemic illness: Chills, myalgias
• Fever of ≥ 38.5
• Tender, hot, swollen wedge-shaped
erythematous area of breast
• Usually one 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
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
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
Causes
• 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
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 between
the groups without lab data.
• Conclusion: Treat with antibiotics
Predisposing factors
• Improper nursing technique
– Timing of feeds
– Poor attachment
• Oversupply of milk
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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
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Damaged nipple (nipple fissure)
Primiparity
Previous history of mastitis
Maternal or neonatal illness
Maternal stress
Work outside the home
Trauma
Genetic
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
• TB where endemic – 1% of cases
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
Candida Infection
Treatment
• Supportive Therapy
– Rest, fluids, pain medication, anti-inflammatory
agents, encouragement
• Continue breast feeding
• Antibiotics that cover Staph and Strep
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Culture results
Severe symptoms
Nipple fissure
No improved after 12-24 hours of milk removal
Treatment
(ACOG)
• Dicloxicillin 500 mg qid
• Erythromycin if PCN allergic
• If resistant to treatment penicillinaseproducing staph, then vancomycin or
cefotetan until 2 days after infection
subsides
• Minimum treatment 10-14 days
Treatment
(Alternative)
• Therapeutic U/S
• Accupunture
• Bella donna, Phytolacca, Chamomilla,
sulphur, Bellis perenis
• Cabbage leaves
• Avoid drinks like coffee with
methylxanthines, decreasing fat intake
Complications
(Other bad things related to
mastitis)
Breast Abscess
Breast Abscess
Breast
abscess with
early skin
necrosis
Abscess
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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
Breast Abscess
Inflammatory
breast cancer
Other Complications
• Distortion of breast
• Chronic inflammatio
Granulomatous Mastitis
• Noncaseating granulomas in a lobular
distribution
• Differential Diagnosis
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TB mastitis
Foreign body
Fat necrosis
Autoimmune: sarcoid, erythema nodusum,
polyarthritis
• Presentation
– Unilateral Breast lump
– No infection identified at presentation
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
Neonatal Mastitis
Neonatal 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
Effect on Milk
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
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
Mastitis