D: Abscess formation in breast tissues.
Two main forms are recognised: puerperal (lactational) and nonpuerperal.
A: Infection. Lactational: most commonly with Staphylococcus aureus, nonpuerperal: S. aureus and anaerobes, often enterococci or bacteroides spp. (TB and actinomycosis are extremely rare causes).
A/R: Main risk factor: lactation, with bacteria gaining access through cracked nipples. Nonpuerperal: smoking, mammary duct ectasia/periductal mastitis, an associated inflammatory breast cancer should be excluded. Also associated with wound infections after breast surgery, diabetes and steroid therapy.
E: Lactational breast abscesses are common and tend to occur soon after starting breastfeeding and on weaning, when incomplete emptying of the breast results in stasis and engorgement. Nonlactational abscesses are more common in those aged 30-60 years and smokers.
H: The patient complains of breast discomfort and the development of painful swelling in an area of the breast. She may complain of feeling unwell and feverish.
Women with a nonpuerperal abscess often have a history of previous infections and systemic upset is less pronounced.
E: Local: Area of breast is swollen, warm, tender and the overlying skin may be inflamed; examination of the nipple may reveal cracks or fissures. In non-puerperal cases there may be evidence of scars or tissue distortion from previous episodes, or signs of duct ectasia, e.g. nipple retraction. Systemic: Pyrexia, tachycardia.
_P Micro: See Abscesses.
Macro: Breast abscesses are frequently loculated. Nonpuerperal tend to arise in periareolar tissues and are often a manifestation of duct ectasia/periductal mastitis.
_I: Imaging: Ultrasound.
Microbiology: Microscopy, culture and sensitivity of pus samples.
M: Medical: Early, cellulitic phase may be treated with antibiotics (flucloxacillin in the case of lactational, with the addition of metronidazole in nonpuerperal abscesses).
Surgical: Lactational: Daily needle aspiration with antibiotic cover may be successful, but in most cases, formal incision and drainage is carried out. Incision should allow full drainage and be cosmetically acceptable; loculi are explored and broken down with a finger. The wound may be packed lightly with antiseptic soaked kaltostat and left open, with daily packing, or primary closure performed with antibiotic cover. Breastfeeding should continue from the non-affected breast and the affected side emptied either manually or with a breast pump. Advice on avoiding cracked nipples.
Non-puerperal: Open drainage should be avoided, or carried out through a small incision. Definitive treatment should be carried out once the infection has settled by the excision of the involved duct system.
C: Mammary fistula formation, rarely overlying skin undergoes necrosis.
P: If untreated, a breast abscess will eventually point and spontaneously discharge onto the skin surface. Nonpuerperal abscesses tend to recur.
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