Presentation on theme: "Index case 1 Year 2 Michaelmas term"— Presentation transcript:
1Index case 1 Year 2 Michaelmas term A painful breastIndex case 1Year 2 Michaelmas term
2The 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.
3Last 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.
4On 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.
5There are palpably enlarged nodes in the right axilla.The left breast and axilla are normal.
11What is the differential diagnosis? Acute breast infection –Cellulitis, AbscessPeri-ductal mastitis (smoking related)Inflammatory carcinomaFat necrosis – (can be spontaneous but usually related to trauma)Sting- wasp? Bee? (ask - it may be as simple as this!)
34Vascular changes: blood flow Transient vasoconstriction then vasodilationIncreased in arteriolar and venous hydrostatic pressureLeakage of fluid and protein into extravascular space
35Vascular changes: vessel wall leaks Gaps develop in endothelium of venulesCytoskeletal reorganisation and transcytosis of vacuoles in endothelial cellesDirect damage of cell wall (e.g in burns)Other leakage from leukocytesAngiogenesis: new vessels leak
36Cellular changesMargination, rolling adhesion of white cells to vessel wall.Movement of leukocytes into tissues to destroy bacteriaHelped by stasis, cytokines, diapedesis, chemotaxis
37Cytokines Local chemical mediator 4 groups: Selectins stimulated by histamineImmmunoglobulinsIntegrinsMucin-like glycoproteins
38diapedesisMovement of white cells through gaps between cells (mainly venules; capillaries in lung)Use collagenases to pierce basement membraneVariation in cell type and time of onset
40Can vary with type of infection/injury: Pseudomonas neutrophils 2-4 daysViral infection: lymphocytes predominateAllergic reaction: eosinophils predominate
41chemotaxis Attraction of leukocytes to bacteria E.g anaphylotoxins produced by interaction of complement, antibodies and bacterial antigens
42An activated leukocyte can: Move. Chemotaxis causes release of calcium and contractile elements in leukocyte. PseudopodsProduce poison: arachidonic acid metabolites; degranulation of lysosomal enzymesStick to endotheliumRecognise bacteria through opsoninsPhagocytoseKill e.g with H2O2
43Unfortunately this process also causes localised damage to tissue Unfortunately this process also causes localised damage to tissue. This can cause disease