Mastitis, Breast Abscess,

and Granulomatous Mastitis 7
Ramesh Omranipour and Mahtab Vasigh

Abstract ment of this condition, more severe

complications like breast abscess could be
Breastfeeding is immunoprotective and World avoided, so that breastfeeding could be contin-
Health Organization recommends exclusive ued in some circumstances.
breastfeeding for about six months with con-
tinuation of breastfeeding for one year or lon- Keywords
ger as mutually desired by mother and infant.
But the target for duration of exclusive breast- Breast abscess · Breastfeeding ·
feeding has not been reached in a significant Granulomatous mastitis · Mastitis ·
number of women. It may be due to inflamma- Pregnancy
tory breast disease such as milk stasis or lacta-
tional mastitis.
In this chapter we discuss the most com-
mon complications of breastfeeding including 7.1 Overview
milk stasis, mastitis, and breast abscess. Also
idiopathic granulomatous mastitis, a less com- The benefits of breastfeeding are well recog-
mon condition, is discussed due to its confus- nized, and the World Health Organization
ing characteristics and not universally-accepted (WHO) recommends exclusive breastfeeding for
treatment strategies. the first 6 months after birth, continuing for up to
Breastfeeding mastitis is inflammation of one  year and beyond [1]. Only 50% of women
the breast that can be infectious or non-­ worldwide reach the 6-month period of
infectious. With proper diagnosis and treat- breastfeeding [2]. It may be due to inflammatory
breast disease such as milk stasis or puerperal
mastitis in some instances, which necessitates
R. Omranipour (*)
Breast Disease Research Center (BDRC), Tehran adding supplements or completely ceasing
University of Medical Sciences, Tehran, Iran breastfeeding [3].
Department of Surgical Oncology, Cancer Institute,
Tehran University of Medical Sciences, Tehran, Iran
e-mail: omranipour@tums.ac.ir
M. Vasigh
Breast Disease Research Center (BDRC), Tehran
University of Medical Sciences, Tehran, Iran

© Springer Nature Switzerland AG 2020 53

S. Alipour, R. Omranipour (eds.), Diseases of the Breast during Pregnancy and Lactation,
Advances in Experimental Medicine and Biology 1252,
https://doi.org/10.1007/978-3-030-41596-9_7
54 R. Omranipour and M. Vasigh

7.2 Mastitis some predisposing factors including primiparity,

obesity, smoking, maternal malnutrition, illness
Mastitis is an inflammatory condition of the of mother or baby, poor positioning of the baby,
breast that is usually associated with lactation cessation of breastfeeding, cracked and sore nip-
and is less common during pregnancy. It can ples [6–8].
progress from the non-infective stage to infective
mastitis. According to variations in the definition
and length of follow up in the postpartum period, 7.2.2 Pathophysiology
the incidence of mastitis in lactating women is and Bacteriology
3–20% with a wide variation among the studies.
The time of occurrence is important in estimating The primary cause is milk stasis [3, 9, 10]. The
the incidence. Breastfeeding-associated inflam- suckling of the infant causes erosions leading to
matory breast diseases appear mostly during the painful nipple and areola. The pain leads to
first 12 weeks postpartum [4, 5]. incomplete emptying of the breast and milk stasis
in the mammary alveoli. Intraductal pressure
rises owing to milk stasis, and milk penetrates
7.2.1 Clinical Presentation into the connective tissue. This penetration opens
intercellular junctions of the ductal epithelium
Mastitis during pregnancy and breastfeeding into the connective tissue, creating a primary
must be differentiated from severe engorgement, sterile inflammation. It is usually followed by a
breast abscess, plugged duct, galactocele, and secondary bacterial infection [10]. The pathogen-
inflammatory breast cancer. The clinical charac- esis of inflammatory breast diseases seems to be
teristics of mastitis include tenderness, swelling, associated with stress [3]. Hypothetically, a
and a warm wedge-shaped area over the breast, change in the intramammary cytokine profile
associated with fever (>38.5 °C), fatigue and flu-­ (e.g. enhanced concentration of proinflammatory
like symptoms (see also Chap. 5). It may or may Th-1-cytokines) occurs because of an elevated
not be accompanied by an infection [5]. The pre- amount of stress around birth that can lead to
sentation can be subtle with few clinical signs in breast infections during the puerperal period. An
the early stages (Fig. 7.1). A large area of breast increase in inflammatory cytokines is accompa-
swelling with overlying skin erythema can be nied by a decrease in anti-inflammatory cyto-
recognized in patients with an advanced infec- kines and local immunodeficiency [11].
tion. Reactive lymphadenopathy may be associ- Nasopharangeal organism from the newborn
ated with axillary pain and swelling. There are babies, such as Staphylococcus aureus and

Fig. 7.1  Mastitis during

pregnancy. Mild
erythema and edema is
seen. (Courtesy of Dr.
Sadaf Alipour)
7  Mastitis, Breast Abscess, and Granulomatous Mastitis 55

Streptococcus, may infect the breast via the dam- treatment of mastitis [21]. S. aureus infections
aged epithelial cells of the nipple-areola complex result in severe clinical symptoms from the
during breastfeeding. Milk stasis in itself would beginning, whereas infections caused by
be a good culture medium and cause symptoms Streptococci are diffuse and cause local abscess
[12, 13]. only in the advanced stage of infection. Infectious
mastitis can be treated efficiently using antibiot-
ics, especially amoxicillin-clavulanate 875  mg
7.2.3 Diagnosis taken twice daily orally for 10–14  days.
Cephalexin or dicloxacillin 500 mg taken every
The diagnosis of mastitis is based on clinical 6  h, orally for 10–14  days, is an alternative
manifestations, laboratory tests are not routinely empiric therapeutic regimen [7]. It is quite rare,
needed [5, 7, 14, 15]. Although differential diag- but puerperal mastitis by methicillin-resistant S
nosis of mastitis from milk stasis is possible by aureus (MRSA) can be very fatal [7].
quantifying the leucocytes and pathogenic bacte- In the setting of severe infection (e.g. hemody-
ria in the breast milk, in practice infectious mas- namic instability or progressive erythema),
titis is usually treated without this test if clinical empiric inpatient therapy with vancomycin (15–
symptoms of the patient do not improve after 24 20 mg/kg per dose every 8–12 h, not to exceed
hours of conservative management. However, a 2 g per dose) should be initiated; then, it is tai-
culture of the breast milk is useful to guide the lored based on culture and sensitivity results
selection of antibiotics; this is particularly impor- [21].
tant in the setting of infection that is severe, hos-
pital acquired, recurrent, or unresponsive to
initial antibiotics [7, 16, 17]. Imaging is useful if 7.3 Breast Abscess
lactational mastitis does not respond to support-
ive care and antibiotics. Ultrasound (US) exam The prevalence of breast abscess during preg-
can help in differentiating mastitis from breast nancy and lactation has been reported from 0.4%
abscess and also from lactational phlegmon to 11% [8, 22]. It could be related to malnutrition,
which can occur in this inflammatory spectrum low immunity, diabetes mellitus, obesity, and
[18]. Owing to the thickening of the skin and poor hygiene of skin and overlying clothing. The
fibrous tissue in mastitis, mammography should nipple and skin are usually the primary sources of
not be performed, unless there are suspicious infection. The predisposing factors leading to
malignant findings. In addition, it is rare to dis- breast abscess include overlying skin diseases,
cover other severe abnormalities in mammogra- minor cracks, and various forms of trauma to a
phy [12]. bulky breast [23].
A breast abscess is determined as a localized
accumulation of infected fluid in the breast tis-
7.2.4 Treatment sue. A hard, tender, and sometimes fluctuant
mass with overlying erythema of the skin is the
Conservative management includes continued most common presentation of a breast abscess
breastfeeding and draining the milk frequently [24] (Fig. 7.2).
[5, 19]. Other measures include supportive care, Breast abscesses are usually associated with
rest and adequate fluid intake, non-steroidal anti-­ lactation (puerperal) but can be non-puerperal
inflammatory drug (NSAID) consumption, warm [8]. Pregnancy over the age of 30  years, first
or cold compress, and analgesics. Antibiotics are pregnancies, gestational age ≥  41  weeks, and
recommended if symptoms have not improved mastitis are considered as risk factors for devel-
[20] although a Cochrane systematic review opment of lactational breast abscesses [25] (see
found insufficient evidence, owing to a lack of also Chap. 5).
studies, to confirm when to use antibiotics in the
56 R. Omranipour and M. Vasigh

Fig. 7.2  Lactating breast abscess in a 40 years-old nurs- of symptoms. (b) After 3  days, fluctuation over the
ing woman 16  months after delivery (first two photo- abscess. (c) After 4 days, impending rupture. The abscess
graphs taken by the patient). (a) Two days after beginning was drained surgically. (Courtesy of Dr. Sadaf Alipour)

7.3.1 Bacteriology is reduced, allowing the woman to continue

breastfeeding her infant with little or no interrup-
S. aureus is the most common causative organism tion. Maintaining the integrity of the breast is
[1], other organisms like Streptococcus or also important, that is, the procedure should
Escherichia coli are less common [26]. MRSA cause minimal or preferably no scarring and
has also been reported as a causative organism in should preserve the function of the breast [28].
several studies [26–28]. Recently, the treatment of lactational abscesses
with single or serial needle aspiration has been
favored in several studies. This is considered to
7.3.2 Diagnosis be effective and less invasive [6, 29, 30]. But cur-
rently it is not clear whether needle aspiration is
If abscess formation is suspected, US is required a more effective option to incision and drainage
for diagnosis and treatment (see also Chap. 3). for treatment of breast abscess [6]. There are
Irregular boundaries, hypo-echoic or anechoic reports of insertion of a drain in the cavity of
mass, thick irregular walls, posterior acoustic large abscesses after aspiration to inhibit early re-­
enhancement and liquid debris (fluid-debris) accumulation of pus. The results are promising,
shades can be observed in the abscess. Sometimes, and this can replace open drainage with a lower
the air in the abscess can cause a bright reflection. rate of complications [31, 32]. Incision and drain-
The floating hyper-echoic dots help in the differ- age (I&D) is recommended if the abscess is sub-
entiation from malignancy [12]. When the patient areolar, the skin over the abscess is thin and
is resistant to treatment and satisfactory recovery shiny, or the abscess appears as if it will burst
is not observed after 1  week of different thera- [33]. I&D is also recommended when the abscess
peutic modalities, US-guided tissue sampling is large (>3 cm) or if there are multiple abscesses
and blood tests for HIV should be considered that fail to respond to aspiration [6, 12]. In order
[19]. to allow continued breastfeeding, incision should
not be made in the areola, and breastfeeding from
the affected breast is recommended even if a
7.3.3 Treatment drain is inserted in the abscess cavity. I&D will
involve hospitalization and regular dressings.
The goal of any of the interventions performed in This is thought to cause considerable distress to
treating an abscess is to remove the infected fluid both mother and baby during what is already a
as soon as possible. Thereby, pain and discomfort difficult time [17]. Daily washing out of the
7  Mastitis, Breast Abscess, and Granulomatous Mastitis 57

wound may be necessary until secretions decrease are mostly sensitive to vancomycin or trime-
or become clear. Usually, the abscess cavity gran- thoprim/sulfamethoxazole and less to rifampin. It
ulates and closes within four weeks [28]. should be presumed that regardless of suscepti-
Antibiotics are also recommended following bility test results, MRSA is resistant to treatment
either a needle aspiration or I&D [28]. Antibiotics with macrolides and quinolones [26].
of choice, such as dicloxacillin or flucloxacillin Continuing breastfeeding helps improve
500  mg 4 times daily orally or first generation inflammation and promote drainage, and can be
cephalosporins may be prescribed. Erythromycin safely performed during antibiotic therapy [13,
or clindamycin may be prescribed for women 26]. If there is no improvement despite these
who are allergic to penicillin. In cases of MRSA, treatments and if there is any suspicion of malig-
a breast milk culture and an assay of antibiotic nancy, a cytology test and biopsy should be per-
sensitivities should be undertaken. MRSA strains formed [26] (Fig. 7.3).

Breast Abscess

Single or serial needle aspiration + Continue breastfeeding + AB

If

Subareolar Large (>3 cm) Thin and shiny skin Multiple Bursting
abscess abscess over the abscess abscesses appearance

Incision + Drainage + Continue breastfeeding + AB

± Tissue biopsy

Hospitalization and regular dressings

Daily washing out of the wound until

secretions become clear

Closure of the wound within 4 weeks

If no improvement or any suspicion of malignancy

Cytology of contents + Biopsy of cavity wall

Fig. 7.3  Treatment of breast abscess during pregnancy or lactation. AB antibiotic therapy
58 R. Omranipour and M. Vasigh

Delayed, inappropriate, or even inadequate treated with corticosteroids, and postpartum

treatment of a breast abscess may result in per- recurrences responded to steroid therapy, as
manent tissue damage, disfigurement, and more well.
extensive lesions, which in about 10% of women
could affect future lactation [6].
7.4.2 Pathogenesis

7.4 Idiopathic Granulomatous Kessler and Wolloch drew attention to the dis-
Mastitis tinction between granulomatous and plasma cell
mastitis. Stains and cultures for bacteria, acid-­
Numerous pathologic processes responsible for fast organisms, and fungi are typically negative
inflammation of the breast, can be included under [46]. Although the role of Corynebacterium spe-
the generic heading of granulomatous mastitis. cies in the pathogenesis of IGM has not been
Idiopathic granulomatous mastitis (IGM) is con- clearly confirmed, remarkable supporting evi-
sidered to be an idiopathic condition with cur- dence has been reported by Taylor et al. [47]. The
rently no universally accepted treatment. Several perilobular distribution and granulomatous char-
etiologies have been considered for IGM.  They acter of the inflammation suggests a cell-­mediated
include hypersensitivity to extravasated lactation reaction to one or more substances concentrated
products, local breast trauma, subclinical infec- in the mammary secretion of lobular cells, but no
tion, autoimmune process, recent history of preg- specific antigen has been identified [34]. The
nancy, lactation, and use of oral contraceptives lesion usually appears after, rather than during
[34–38]. High levels of serum prolactin and pregnancy [48]. Coexistent erythema nodosum
distension of the acini and ducts may result in has been reported [49].
rupture of these structures, inducing a granulo-
matous response. Other causes of mammary
granuloma formation such as sarcoidosis, 7.4.3 Diagnosis
Wegener granulomatosis, tuberculosis, and a fun-
gal infection must be excluded before a confirma- Women with IGM typically present with a dis-
tive diagnosis [39]. tinct, firm-to-hard mass that involves any part of
the breast but tends to spare the subareolar
region (Fig. 7.4). Bilateral involvement is uncom-
7.4.1 Concerns in Pregnancy mon. The clinical findings often suggest carci-
and Lactation noma, and mammography may also be described
as suspicious [34]. Synchronous breast cancer
IGM is unusual in pregnancy, although it usually and IGM were reported only in a few case reports.
occurs few  years after lactation [40] (see also Although IGM is not the underlying cause of
Chap. 5). In a retrospective study of 25 women breast malignancy, the diagnosis of breast cancer
diagnosed with IGM from Malaysia, 1 patient should always be kept in mind. Any other lesions
was 25 weeks pregnant and 5 patients were lac- in the presence of IGM should be assessed to rule
tating at the time of presentation [41]. In addi- out breast cancer [50]. The lesions are frequently
tion, in a report of 24 patients from Jordan, 4 hypoechoic on US, and are mostly detected by
were pregnant at the time of presentation [42]. this modality rather than by mammography.
There were few other case reports of IGM at Owing to the suspicious inherent differential
11 weeks [43], 17 weeks [44], and 7 months of diagnoses, a histologic diagnosis with needle
pregnancy [45]. The first two cases of IGM were biopsy is necessary.
7  Mastitis, Breast Abscess, and Granulomatous Mastitis 59

Fig. 7.4  Idiopathic Granulomatous Mastitis (a) In the right breast of a pregnant woman (26 weeks of gestational age);
(b) In the left breast of a 31 years-old woman during lactation

Persistence or recurrence of the inflammatory were the first to investigate the efficacy of differ-
process has been described after biopsy, which ent treatments, and they concluded that cortico-
may lead to skin ulceration [51]. steroid is an appropriate option for the treatment
of the disease [59]. Furthermore, Sakurai et  al.
sought this pharmaceutical approach, and they
7.4.4 Treatment authenticated that corticosteroids could be effi-
cient in 87% of patients without any relapse [37].
There is no universally accepted treatment for The results were validated by Su et al. while their
IGM [34–37]. The most commonly used thera- research implied that low doses of corticosteroids
pies include surgical excision of the granuloma, were efficient [60]. Some authors concluded that
drainage of the wound, and concomitant steroid steroid therapy is effective and resolution can be
therapy [34–37]. Others suggest the use of antibi- obtained without surgery [37]. Other researchers
otics, wide surgical resection, mastectomy, and found that surgical excision and antibiotics
use of immunosuppressants [34–37]. Several should be the primary treatment modalities [38,
studies have proved that recurrences after surgi- 54].
cal excision are frequent, even after bilateral There are reports demonstrating that clinical
mastectomy [42, 53]. The rare coexistence of observation of the patient associated with educa-
breast cancer with IGM supports the argument tion and reassurance can be an effective strategy
against operative management of this benign to manage IGM with resolution after an average
condition [55]. Currently, surgical management of about 7 months [55].
has become less prominent in treating IGM, and With such wide variations in treatment pat-
non-surgical recommendations have become terns, it is not surprising that published recur-
more common including medications (oral or rence rates can approach 50% [51]. In fact,
topical steroids, methotrexate, azathioprine, and current treatment methods are considered subop-
anti-tuberculosis medications) or close observa- timal as all therapies can have significant adverse
tion [42, 53, 56–58]. There are significant reports effects [34–36, 54].
in the literature indicating that treatment with Despite the relatively high incidence of the
methotrexate is effective, can prevent complica- disease in Iran, the authors have only had the
tions, and can limit adverse effects associated experience of 4 cases of IGM during pregnancy
with corticosteroid use [53]. in around 25 years of surgical practice. All were
Corticosteroids have been effective in resolv- controlled with low-dose prednisolone (15  mg
ing the lesions after a specific infectious etiology per day during pregnancy and postpartum peri-
has been ruled out [59]. In 1980, DeHertogh et al. ods). Of these, 2 stopped breastfeeding because
60 R. Omranipour and M. Vasigh

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