VCOM Carolinas Research Day 2023

Clinical Case-Based Reports

Mastitis and Breast Abscess in the Postpartum Patient: A Case Report J. Cody Urban OMS-III, Michaeleena Carr DO, Lindsey Tjiattas-Saleski, DO, MBA PRISMA Health Tuomey - Sumter, SC and Edward Via College of Osteopathic Medicine Carolinas - Spartanburg, SC

Abstract # CBR-13



Case Report • Breastfeeding rates in the United States have increased from 35 to 55 percent in the last two decades 1 • The World Health Organization (WHO) recommends infants initiating breastfeeding within an hour of birth and continuing exclusive breastfeeding until 6 months of age 2 • Mastitis is a common occurrence in lactating women, with one of the major complications being the progression to breast abscess • With the number of women breastfeeding steadily increasing, the number of women who experience mastitis can be expected to rise as well • Breast pain is one of the most common reasons women stop breastfeeding 3 • Mastitis and breast abscesses can often mimic other conditions such as inflammatory breast cancer and idiopathic granulomatous mastitis, a benign chronic inflammatory breast condition 4 • Correctly diagnosing mastitis is imperative so that other conditions are not missed and treatment can be directed appropriately • While lactational mastitis is not uncommon, this patient’s large abscess involvement and her need to receive inpatient care and antibiotics make it a unique case worthy of discussing • 34-year-old female 8 weeks postpartum presents to ED with left-sided breast pain • 10 days prior was treated at urgent care for redness around breast as well as a blocked milk duct. She was prescribed oxacillin and her fever resolved and the breast redness lessened but did not resolve completely • Child was exclusively breast fed and was previously able to express milk, but now the patient presents with pain and increased redness traveling up the left axilla, the inability to express milk, and a heart rate consistently in the range of 110 bpm • Blood cultures were drawn and IV fluids, vancomycin, and analgesics were started • OBGYN consulted and ultrasound performed- large hypoechoic area in left breast that was believed to be retained milk • No improvement on antibiotics, so surgery was consulted and aspiration was recommended to rule out an abscess • Lactation care was provided to encourage pumping with use of massage and warm compresses • Aspiration was performed under local anesthesia to confirm that the material was purulent • Incision and drainage was performed under general anesthesia which encountered a large pocket containing nearly 1000 ml of purulent fluid which was positive for S. aureus • Loculations were broken up, wound was irrigated, and ¼ inch Penrose drain was placed • Patient was treated inpatient for 7 days with vancomycin and cefazolin • Patient discharged on cefalexin and appeared to be doing well on follow-up

Figure 2 . Ultrasound of patients left breast

Figure 1 . Location of pocket

Condition • Mastitis occurs in up to 33 percent of lactating women, with 3 to 11% percent of cases progressing to breast abscess 5,6 • Most cases of mastitis occur within the first 6 weeks after delivery 7 • Most associated with milk stasis and infectious agents 5 • Staphylococcus aureus and Streptococcal species 7 History/Physical Exam • Present with breast pain, erythema, warmth of affected area, edema, and potentially fever, nausea, vomiting, and purulent drainage if an abscess is present 7 Diagnosis • Diagnosis is typically clinical, but ultrasound can be helpful to rule out a breast abscess • Differential diagnoses can include sore nipples from latch issues, a clogged duct or galactocele, granulomatous mastitis, and inflammatory breast cancer 8,9 • Culture of breastmilk can be helpful for choosing most specific antibiotic 8 Treatment • Initial interventions can be attempted with NSAIDs, cold compress, and breast emptying 10 • First choice antibiotics are penicillinase-resistant penicillins, like dicloxacillin 11 , substituted by cephalexin or clindamycin a penicillin is not appropriate for the patient • Trimethoprim-sulfamethoxazole or clindamycin can be used for MRSA coverage 10 • If antibiotics do not resolve the infection, procedures such as needle aspiration or incision and drainage may be considered. Prognosis • With treatment, patients with acute lactational mastitis, even in the event of abscess, tend to have excellent recovery rates

Figure 3 . labs on admission

Figure 4 . Example image of incision for I&D of breast abscess 9

Figure 5. example image of Penrose drain 9




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