Breast Abscess
The majority of breast infections may be divided into four groups:
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neonatal infection
infections in lactating women
infections in non-lactating women
infections resulting from localised skin infection
Symptoms
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Breast abscess
o Localized breast edema, erythema, warmth, and pain
o History of previous breast abscess is common.
o Associated symptoms of fever, vomiting, and spontaneous drainage
from the mass or nipple
o May be lactating
In neonates
response to maternal hormones the breast bud in newborn babies may be enlarged and
this can occasionally become infected.
The organism involved is usually Staphylococcus aureus, but on occasion Escherichia
coli may be detected.
Treatment is with appropriate antibiotics, although if an abscess is present, aspiration
then drainage may be appropriate. If drainage is required, care should be taken not to
damage the neonatal breast bud, by placing any incision as peripheral as possible.
In lactating women
Breast feeding may cause abrasion of the skin around the breast and, on occasion,
cracking of the nipple. This permits the entry of infective organisms, most commonly
Staphylococcus aureus but also Staphylococcus epidermidis and streptococci. This
may result in a circumareolar breast abscess, or deep infection of the lactiferous ducts.
Uncommonly, infections arise in the sebaceous glands (of Montgomery) of the areola,
where they resemble skin boils.
The initial presentation is that of a diffuse cellulitis which localises into an abscess
after several days.
The patient may be generally unwell with a spiking fever. The affected area of the
breast is painful and tender, red and warm. There may be a purulent discharge if the
lesion is extensive.
Breast milk should be obtained for culture and sensitivity.
Blind therapy is with flucloxacillin, assuming infection with staphylococcus. Other
antibiotics which may adversely effect the baby should of course be avoided. Use
erythromycin if penicillin-allergic.
Continuing breast feeding should be encouraged as this helps to drain the affected
segment of the breast. It is important to empty the affected breast and if it is too tender
for feeding to continue, the baby should be fed from the non-infected breast and milk
expressed from the infected one.
If the infection persists after an initial course of flucloxacillin (and results of culture
and sensitivity are not available), then co-amoxiclav, which has a wider spectrum of
action, may be tried.
Any abscess which develops should be recurrently aspirated or incised and drained.
Non-lactating breast infection
Breast infection in non-lactating women most commonly occurs in the periareolar
region of the breast. Less commonly however, in patients with certain pre-existing
conditions such as diabetes, infection may also be seen in peripheral breast tissue.
Peri-areolar
This is a condition where non-dilated subareolar breasts ducts become infected. It
most commonly affects young women, with a mean age of 32 years.
The condition may present with periareolar inflammation, and the breast may be
tender. There may be a history of nipple discharge and on examination the nipple may
be retracted and there may be an associated inflammatory mass or abscess.
Aetiology - Histologically, periductal mastitis is characterised by active inflammation
around non-dilated subareolar breast ducts. This distinguishes it from mammary duct
ectasia which is a condition of older women where duct dilatation is more
pronounced.
90% of women with periductal mastitis smoke, and it has been suggested that
smoking in some way results in damage to the subareolar ducts which then become
infected. Infective organisms may be aerobic or anaerobic and include
Staphylococcus aureus, Enterococci, Anaerobic streptococci and Bacteroides species.
Treatment - As with other breast infections treatment is with appropriate antibiotics,
and abscesses should be aspirated or incised and drained.
Any residual inflammation or masses following treatment should be further
investigated to exclude a neoplasm.
Recurrent breast infection or abscesses require surgery to remove the diseased duct.
A common complication of draining a periareolar abscess is the formation of a
mammary duct fistula.
Skin Associated
The skin of the breast may become affected by cellulitis or abscess formation
following direct infection often by Staphylococcus aureus or rarely certain fungi.
Such infections occur in women whose skin has been damaged by previous surgery or
radiotherapy, but also occur in women predisposed to infection due to being
overweight, having large breasts or due to poor personal hygiene.
Sebaceous cysts may also provide a port of entry for infection and recurrent infections
in the inframammary fold may be due to hidradenitis suppurativa.
Thrombophlebitis of vessels overlying the breast is called Mondor's disease.
Treatment is with appropriate antibiotics and the aspiration or incision and drainage of
abscesses.
Advice may be given if necessary about weight loss, keeping the breasts as clean and
dry as possible i.e. avoiding talc, skin creams and the wearing of a cotton bra or
cotton T shirt under a bra.
In cases of hidradenitis suppurativa, excision of affected skin prevents further
infection in a proportion of patients.