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Breast abscess
OVERVIEW: Collection of pus usually localized. Can be associated with lactation or fistulous tracts secondary to squamous epithelial neoplasm or duct occlusion.
System(s) affected: Skin/Exocrine
Genetics: N/A
Incidence/Prevalence in USA: Common
Predominant age:
• Subareolar abscess - postmenopausal
• Puerperal abscess - premenopausal
Predominant sex: Female
SIGNS AND SYMPTOMS: • Tender breast lump, fluctuant, usually unilateral
• Erythema
• Draining pus
• Local edema
• Systemic malaise
• Fever
• Nipple and skin retraction
• Proximal lymphadenopathy
CAUSES: • Puerperal abscesses - blocked lactiferous duct
• Subareolar abscess - squamous epithelial neoplasm with keratin plugs or ductal extension with associated inflammation
• Peripheral abscess - stasis of the duct
RISK FACTORS: • Puerperal mastitis 5-11% go on to abscess
• Diabetes
• Rheumatoid arthritis
• Steroids
• Silicone/paraffin implants
• Lumpectomy with radiation
• Heavy cigarette smoking
• Nipple retraction
DIAGNOSIS DIFFERENTIAL DIAGNOSIS: • Carcinoma (inflammatory)
• Tuberculosis (may be associated with HIV infection)
• Actinomycosis
• Typhoid
• Sarcoid
• Syphilis
• Hydatid cyst
• Sebaceous cyst
LABORATORY: • Leukocytosis
• Elevated sedimentation rate
• Culture and sensitivity of drainage to identify pathogen, usually staphylococci or streptococcus. Non-lactational abscess associated with anaerobic bacteria.
Drugs that may alter lab results: None
Disorders that may alter lab results: None
PATHOLOGICAL FINDINGS: • Squamous metaplasia of the ducts
• Intraductal hyperplasia
• Epithelial overgrowth
• Fat necrosis
• Duct ectasia
SPECIAL TESTS: None
IMAGING: • Ultrasound
• Mammogram - cannot exclude carcinoma
DIAGNOSTIC PROCEDURES: • Aspiration for culture
• Fine needle aspiration (FNA) not accurate to exclude carcinoma
TREATMENT APPROPRIATE HEALTH CARE: Outpatient, unless systemically immunocompromised
GENERAL MEASURES: • Cold compresses
• Expression of milk
SURGICAL MEASURES: • Aspiration possibly under ultrasound guidance
• Incision and drainage with removal of loculations and biopsy of all non-puerperal abscesses to rule out carcinoma
• Open all fistulous tracts, especially in nonlactating abscesses
ACTIVITY: No restrictions
DIET: No restrictions
PATIENT EDUCATION: • Care of wound
• Breast feeding precautions
MEDICATIONS DRUG(S) OF CHOICE: • Nonsteroidal anti-inflammatory agents
• Erythromycin 250-500 mg qid
• First generation, oral cephalosporin
• Cephalexin 500 mg bid
• Cefaclor 250 mg tid
• Amoxicillin-clavulanate (Augmentin) 250 mg tid
• Clindamycin 300 mg tid if anaerobes suspected
Contraindications: Allergy to antibiotic
Precautions: Refer to manufacturer's profile of each drug
Significant possible interactions: Refer to manufacturer's profile of each drug
ALTERNATIVE DRUGS: N/A
FOLLOW UP PATIENT MONITORING: Assure resolution to exclude carcinoma
PREVENTION/AVOIDANCE: • Early treatment of mastitis with milk expression and cold compresses
• Early treatment with antibiotics
POSSIBLE COMPLICATIONS: Fistula
EXPECTED COURSE AND PROGNOSIS: Good. Complete healing expected in 8 to 10 days, particularly if abscess can be incised and drained.
MISCELLANEOUS ASSOCIATED CONDITIONS: N/A
AGE-RELATED FACTORS:
Pediatric: N/A
Geriatric: N/A
Others: N/A
PREGNANCY: Most commonly associated with postpartum lactation
SYNONYMS: • Mammary abscess
• Peripheral breast abscess
• Subareolar abscess
• Puerperal abscess
ICD-9-CM: 611.0 Acute, chronic, nonpuerperal
675.1 Puerperal, postpartum
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