RADY 413 Case Presentation Ed. John Lilly, MD 30 year old lactating - - PowerPoint PPT Presentation

RADY 413 Case Presentation

• Ed. John Lilly, MD

30 year old lactating female presenting with worsening right breast swelling and erythema, with new hardened area

 AD is a 30 y/o previously healthy G1P1001 F who presents with a 2-

week history of worsening right breast pain and expanding erythema. She is currently 10 wks postpartum and exclusively pumping. Pt first noticed erythema two weeks ago and had been self-managing with warm compresses. 5 days ago, she received a prescription of dicloxacillin from her OB. Despite continued treatment, she reported a dramatic increase in size and erythema of the breast, in addition to new low grade fevers and chills.

 Physical exam:

▪ Induration and erythema at 12-1 o’clock position at the R breast ▪ 8cm tense and tender mass at same position

 Focused R breast ultrasound

8

Transverse image Longitudinal image

 Irregular 7.5 x 4.6 cm fluid

collection with overlying skin thickening, consistent with an abscess

 BI-RADS 2: Benign  Ultrasound-guided

aspiration recommended

 Ultrasound-guided aspiration of abscess

 Following informed consent, utilizing

sterile technique and local anesthesia with 1% lidocaine, under ultrasound guidance, a 18g needle was used to aspirate the abscess. 100 mL of turbid, light brown / serosanguinous, milky fluid was withdrawn; the initial 10 cc aliquot was sent to Micro lab for gram stain and culture and sensitivity.

 Small to moderate sized residual

collection was undrainable due to complicated nature of collection

Needle intraprocedure

100 cc infected thick milky fluid were aspirated Right breast post aspirate with wedge-shaped erythema and skin induration with improved mass effect at 12/1:00 in breast

 Preliminary cultures on initial 10cc aliquot of aspirate 3+ PMNs and 4+

Gram+ cocci

 Pt evaluated at Breast Surg clinic and was switched from PO

dicloxacillin to PO clindamycin 300mg q6h

▪ Surg breast clinic will continue to follow closely

 Lactational mastitis1,3,5 ▪ Estimated 2-10% of breastfeeding women ▪ Typically as a result of either poor drainage or prolonged

engorgement

▪ Risk factors include blocked ducts, cracked nipples, antifungal creams, and breast pump usage

▪ Clinical presentation

▪ Breast swelling, tenderness, erythema ▪ Fevers >38.3C ▪ Myalgias, chills, malaise

 Lactational mastitis1,3,5

▪ Microbiology

▪ Most likely MSSA and MRSA ▪ Less commonly s. pyogenes, e. coli, bacteroides spp., corynebacterium spp.

▪ Treatment

▪ Symptomatic treatment include NSAIDs, cold compressions, and continuation of milk expression ▪ Empiric abx include dicloxacillin or cephalexin 500mg q6h (clindamycin 300-450mg q8h w/beta-lactam hypersensitivity) ▪ If risk of MRSA, use TMP/SMX double strength BID or clindamycin 300mg q8h

▪ May progress to abscess formation if infection not treated promptly

 Puerperal breast abscess2,5

▪ 14% of all breast abscesses ▪ Formation usually 5-28 days after onset of symptoms of mastitis ▪ DDx:

▪ Plugged duct - absence of systemic symptoms ▪ Galactocele - nontender, simple/complex milk cyst/mass on US ▪ Inflammatory Breast Cancer - consider if infection does not resolve + clinical correlation

▪ Treatment includes aspiration vs surgical I&D

▪ Aspirations may need to be repeated every 2-3 days until no collection remains

34 yo woman with history of nipple inversion with new focal breast tenderness and erythema Abscess was drained under ultrasound

• guidance. Stain

and culture showed mixed flora, including corynebacterium spp.

Young female patient, currently lactating presenting with a palpable breast mass. Compression magnification mammogram demonstrates fat-fluid levels in palpable mass Targeted US demonstrates an oval mass that contains fat and fluid BI-RADS 2: Benign; aspiration not indicated

Peau d’orange on visual inspection; PET positive for left breast skin involvement and underlying FDG tracer-avid infiltrating tumor. Triple negative by IHC. Pt underwent neoadjuvant chemotherapy followed by L mastectomy.

1.

Dixon, J. M., Chagpar, A. B., Sexton, D. J., Baron, E. L., Eckler, K. (2018). Lactational mastitis.

• UpToDate. Last updated June 12th, 2018.

2.

Dixon, J. M., Chagpar, A. B., Sexton, D. J., Baron, E. L., Chen, W. (2018). Primary breast abscess.

• UpToDate. Last updated May 9th, 2018.

3.

Kvist, L. J., Larsson, B. W., Hall-Lord, M. L., Steen, A., & Schalén, C. (2008). The role of bacteria in lactational mastitis and some considerations of the use of antibiotic treatment. International breastfeeding journal, 3(1), 6.

4.

Dixon, J. M., & Khan, L. R. (2011). Treatment of breast infection. BMJ, 342(11), d396.

5.

Dener, C., & İnan, A. (2003). Breast abscesses in lactating women. World journal of surgery, 27(2), 130-133.

6.

Amir, L. H., Forster, D., McLachlan, H., & Lumley, J. (2004). Incidence of breast abscess in lactating women: report from an Australian cohort. BJOG: An International Journal of Obstetrics & Gynaecology, 111(12), 1378-1381.

7.

Jahanfar, S., Ng, C. J., & Teng, C. L. (2013). Antibiotics for mastitis in breastfeeding women. The Cochrane Library.

8.

Acsearch.acr.org. (2018). Appropriateness Criteria. [online] Available at: https://acsearch.acr.org/list [Accessed 24 Jun. 2018].