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This is Rosemary Schleicher and she was admitted for pain, swelling, and redness in her left breast, along with fever.
She delivered her baby 3 weeks ago, and since then, things have been going as expected for her. She’s been breastfeeding, and two days ago, she called me to report that her left breast hurt, seemed swollen, was red, and she felt feverish, with a temperature of 101.4
I saw her that day in the clinic and found the breast to have the classical findings of redness, and tenderness. The breast was firmer than the other, non-infected breast, but had no distinct masses or densities. I diagnosed acute mastitis, and recommended she begin Dicloxacillin. I asked that she call me the next day to report her progress. I did not obtain a culture, since there was no purulence to culture, and milk cultures are not likely to be helpful unless the patient is quite ill, hospitalized, or has not responded to usually curative antibiotics.
Puerperal Mastitis
Breast infections like this can come on very suddenly and advance quickly. This was a relatively early case of mastitis, without any abscess formation, and as most of these infections are due to strep or staph, dicloxacillin is a pretty good choice, is usually effective, and results in at least modest improvement within 24 hours and substantial improvement in 48 hours.
Mastitis is a relatively common problem among postpartum women, affecting up to 10% of lactating women, and primarily those who have experienced some difficulties with breastfeeding, including cracked nipples, persistent engorgement, and those with previous breast infections.
Plugged milk ducts can lead to a tender lump in the breast, but don’t have the same skin erythema and maternal temperature elevations seen with mastitis. Galactoceles, or retained collections of milk are non-tender lumps, presenting quite differently from the typical mastitis case. Inflammatory breast cancer can present with a tender, red, swollen breast, but is rare in comparison to the common mastitis, and often has worrisome skin changes called peau d’orange or orange peel changes. As you might have predicted, most cases of inflammatory breast cancer in lactating women are diagnosed only after what was thought to be simple mastitis did not improve with standard antibiotics.
I told her to continue to breast feed on both sides even though it might be painful, since it is important to drain the milk from the affected side and not allow stagnation to occur. I asked her to call me the next day to report her progress because there are two complications that can occur that could become apparent within a day or two of initiating treatment.
The first worrisome complication is a breast abscess. It is worrisome because if she has an abscess, it will need to be drained surgically. Postponing the surgical drainage only allows the abscess to get worse.
The other complication we sometimes see is antibiotic-resistant bacteria causing the infection. In this case, after 24 hours, the patient will not be much better and will probably be worse.
In the case of Mrs. J.R., she called the next day to say she was worse, not better, and her fever was up to 103.4. I met her in the emergency room and rechecked the breast. The change was dramatic. In 24 hours, she had gone from a relatively mild puerperal mastitis, to a much more serious infection with marked redness, tenderness and swelling of the left breast. In addition, there was now a thickness or fluctuance of the breast in the upper outer quadrant. I asked the general surgeon on call to take a look at her with me. He agreed that an abscess had probably formed and that the responsible bacteria was probably not sensitive to the dicloxacillin. A breast ultraound scan confirmed our suspicions of a likely breast abscess.
He took her to the operating room and drained about 15 cc of pussy fluid, leaving a drain in place to discourage reaccumulation. We cultured the pus and found methicillin-resistant staph aureus in large numbers. In the meantime, we had already started Vancomycin intravenously and by the time the culture reports came back, she was dramatically improved. The combination of surgical drainage and Vancomycin proved to be powerfully effective in bringing this breast abscess under control.
As you can see today, the drain has been removed and the redness of the breast is almost completely gone. She has no fever and will be sent home soon.
