A painful breast

Index case 1

Year 2 Michaelmas term

The case:

4 weeks ago Mrs F. E. is aged 24 and was delivered of a healthy 4.2Kg baby boy. She has been an Type 1 diabetic since the age of 11 with a good control pattern. She is a smoker and has been unable to stop during the pregnancy. She has been breast feeding with some bottle supplementary feeds.

Last week, she noticed that her right breast had become painful and tender, particularly in the inner upper quadrant. Milk production appeared to be normal, although breast feeding was painful on that side.

On examination the right breast is red in the inner upper quadrant and swollen. The skin overlying the area has an orange skin appearance and is blackened in the centre of the area. The nipple appears normal. The left breast appears normal. The right inner upper quadrant is very tender and hot to the touch. There is a hard lump palpable in the same area, with ill-defined margins. The skin shows some dimpling on pressure indicating subcutaneous oedema.

There are palpably enlarged nodes in

the right axilla.

The left breast and axilla are normal.

What is the differential diagnosis?

What is the differential diagnosis?

• Acute breast infection -

Cellulitis ?

Abscess?

What is the differential diagnosis?

• Acute breast infection -

Cellulitis ?

Abscess?

• Periductal mastitis

Periductal mastitis

What is the differential diagnosis?

•   Acute breast infection –Cellulitis, Abscess

• Peri-ductal mastitis (smoking related)• Inflammatory carcinoma• Fat necrosis – (can be spontaneous but

usually related to trauma)• Sting- wasp? Bee? (ask - it may be as

simple as this!)

Bee stings

Which is most likely and why?

Which is most likely and why?

• Mastitis/abscess

Which is most likely and why?

• Mastitis/abscess

• Breast feeding; diabetes

How would you manage this case?

Triple assessment

• History and examination

• Imaging

• Tissue and or bacteriological diagnosis

Breast abscess: ultrasound useful for detecting fluid cavities

Mammography non-specific and very painful

Tissue/bacteriology

• Histology

• Milk culture

• Blood culture

Likely organisms

• Staphylococcus aureus

• Escherichia coli

• MRSA

• Pseudomonas aeruginosa

What is the difference between cellulitis and an abscess?

cellulitis

• diffuse inflammatory process with little focal necrosis and pus. Inflammatory cells present in the tissues- neutrophils predominate with tissue oedema.

cellulitis

abscess

• A cavity containing pus surrounded by an inflammatory response.

• Pus- neutrophils, bacteria and necrotic debris

Treatment of mastitis

Treatment of mastitis

• Early treatment with antibiotics to prevent abscess development

- flucloxacillin

-consider IV with diabetes or very unwell/dehydrated

Continue to breast-feed?

Continue to breast-feed?

• Yes- if can manage

• Most antibiotics OK to use in breast-feeding

• Bacteria killed in baby’s stomach

• May prefer to feed from normal side

What if there is an abscess?

What if there is an abscess?

• Small abscess can be drained with a needle under LA

• Large abscess may require open drainage LA or GA

Mastitis a good example of acute inflammation

Features of acute inflammation

• Vascular changes: blood flow

• Vascular changes: vessel wall leaks

• Cellular changes

Vascular changes: blood flow

• Transient vasoconstriction then vasodilation

• Increased in arteriolar and venous hydrostatic pressure

• Leakage of fluid and protein into extravascular space

Vascular changes: vessel wall leaks

• Gaps develop in endothelium of venules

• Cytoskeletal reorganisation and transcytosis of vacuoles in endothelial celles

• Direct damage of cell wall (e.g in burns)

• Other leakage from leukocytes

• Angiogenesis: new vessels leak

Cellular changes

• Margination, rolling adhesion of white cells to vessel wall.

• Movement of leukocytes into tissues to destroy bacteria

• Helped by stasis, cytokines, diapedesis, chemotaxis

Cytokines

• Local chemical mediator

• 4 groups:

• Selectins stimulated by histamine

• Immmunoglobulins

• Integrins

• Mucin-like glycoproteins

diapedesis

• Movement of white cells through gaps between cells (mainly venules; capillaries in lung)

• Use collagenases to pierce basement membrane

• Variation in cell type and time of onset

In acute bacterial infection:

• Leukocytes 6-24 hours

• Monocytes 24-48 hours

• Lymphocytes> 72 hours

Can vary with type of infection/injury:

• Pseudomonas neutrophils 2-4 days

• Viral infection: lymphocytes predominate

• Allergic reaction: eosinophils predominate

chemotaxis

• Attraction of leukocytes to bacteria

• E.g anaphylotoxins produced by interaction of complement, antibodies and bacterial antigens

An activated leukocyte can:• Move. Chemotaxis causes release of calcium and

contractile elements in leukocyte. Pseudopods• Produce poison: arachidonic acid metabolites;

degranulation of lysosomal enzymes• Stick to endothelium• Recognise bacteria through opsonins• Phagocytose• Kill e.g with H2O2

Unfortunately this process also causes localised damage to tissue.

This can cause disease

Examples of acute inflammatory disease?

Examples of acute inflammatory disease?

• Pelvic inflammatory disease• Puerperal sepsis• Septic shock• Glomerulonephritis• Asthma• Transplant rejection• Atherosclerosis• arthritis

If there is one thing to remember about acute inflammation it

would be:

The neutrophil