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A painful breast Index case 1 Year 2 Michaelmas term.

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Presentation on theme: "A painful breast Index case 1 Year 2 Michaelmas term."— Presentation transcript:

1 A painful breast Index case 1 Year 2 Michaelmas term

2 The case: 4 weeks ago Mrs F. E. is aged 24 and was delivered of a healthy 4.2Kg baby boy. She has been an Type 1 diabetic since the age of 11 with a good control pattern. She is a smoker and has been unable to stop during the pregnancy. She has been breast feeding with some bottle supplementary feeds.

3 Last week, she noticed that her right breast had become painful and tender, particularly in the inner upper quadrant. Milk production appeared to be normal, although breast feeding was painful on that side.

4 On examination the right breast is red in the inner upper quadrant and swollen. The skin overlying the area has an orange skin appearance and is blackened in the centre of the area. The nipple appears normal. The left breast appears normal. The right inner upper quadrant is very tender and hot to the touch. There is a hard lump palpable in the same area, with ill-defined margins. The skin shows some dimpling on pressure indicating subcutaneous oedema.

5 There are palpably enlarged nodes in the right axilla. The left breast and axilla are normal.

6

7 What is the differential diagnosis?

8 Acute breast infection - Cellulitis ? Abscess?

9 What is the differential diagnosis? Acute breast infection - Cellulitis ? Abscess? Periductal mastitis

10

11 What is the differential diagnosis? Acute breast infection –Cellulitis, Abscess Peri-ductal mastitis (smoking related) Inflammatory carcinoma Fat necrosis – (can be spontaneous but usually related to trauma) Sting- wasp? Bee? (ask - it may be as simple as this!)

12 Bee stings

13 Which is most likely and why?

14 Mastitis/abscess

15 Which is most likely and why? Mastitis/abscess Breast feeding; diabetes

16 How would you manage this case?

17 Triple assessment History and examination Imaging Tissue and or bacteriological diagnosis

18 Breast abscess: ultrasound useful for detecting fluid cavities

19 Mammography non-specific and very painful

20 Tissue/bacteriology Histology Milk culture Blood culture

21 Likely organisms Staphylococcus aureus Escherichia coli MRSA Pseudomonas aeruginosa

22 What is the difference between cellulitis and an abscess?

23 cellulitis diffuse inflammatory process with little focal necrosis and pus. Inflammatory cells present in the tissues- neutrophils predominate with tissue oedema.

24 cellulitis

25 abscess A cavity containing pus surrounded by an inflammatory response. Pus- neutrophils, bacteria and necrotic debris

26 Treatment of mastitis

27 Early treatment with antibiotics to prevent abscess development - flucloxacillin -consider IV with diabetes or very unwell/dehydrated

28 Continue to breast-feed?

29 Yes- if can manage Most antibiotics OK to use in breast-feeding Bacteria killed in baby’s stomach May prefer to feed from normal side

30 What if there is an abscess?

31 Small abscess can be drained with a needle under LA Large abscess may require open drainage LA or GA

32 Mastitis a good example of acute inflammation

33 Features of acute inflammation Vascular changes: blood flow Vascular changes: vessel wall leaks Cellular changes

34 Vascular changes: blood flow Transient vasoconstriction then vasodilation Increased in arteriolar and venous hydrostatic pressure Leakage of fluid and protein into extravascular space

35 Vascular changes: vessel wall leaks Gaps develop in endothelium of venules Cytoskeletal reorganisation and transcytosis of vacuoles in endothelial celles Direct damage of cell wall (e.g in burns) Other leakage from leukocytes Angiogenesis: new vessels leak

36 Cellular changes Margination, rolling adhesion of white cells to vessel wall. Movement of leukocytes into tissues to destroy bacteria Helped by stasis, cytokines, diapedesis, chemotaxis

37 Cytokines Local chemical mediator 4 groups: Selectins stimulated by histamine Immmunoglobulins Integrins Mucin-like glycoproteins

38 diapedesis Movement of white cells through gaps between cells (mainly venules; capillaries in lung) Use collagenases to pierce basement membrane Variation in cell type and time of onset

39 In acute bacterial infection: Leukocytes 6-24 hours Monocytes hours Lymphocytes> 72 hours

40 Can vary with type of infection/injury: Pseudomonas neutrophils 2-4 days Viral infection: lymphocytes predominate Allergic reaction: eosinophils predominate

41 chemotaxis Attraction of leukocytes to bacteria E.g anaphylotoxins produced by interaction of complement, antibodies and bacterial antigens

42 An activated leukocyte can: Move. Chemotaxis causes release of calcium and contractile elements in leukocyte. Pseudopods Produce poison: arachidonic acid metabolites; degranulation of lysosomal enzymes Stick to endothelium Recognise bacteria through opsonins Phagocytose Kill e.g with H2O2

43 Unfortunately this process also causes localised damage to tissue. This can cause disease

44 Examples of acute inflammatory disease?

45 Pelvic inflammatory disease Puerperal sepsis Septic shock Glomerulonephritis Asthma Transplant rejection Atherosclerosis arthritis

46 If there is one thing to remember about acute inflammation it would be:

47 The neutrophil


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