A 25-year-old woman, gravida 1 para 1, comes to the office for evaluation of fever and right breast pain. The patient is 2 weeks postpartum after an uncomplicated pregnancy and vaginal delivery. She has been breastfeeding every 2-3 hours; however, the infant has had difficulty with latching due to the mother's inverted nipples. Yesterday, the patient developed constant sharp pain in the side of her right breast as well as fever, chills, nausea, and body aches. The pain is worsening, especially during breastfeeding. She has been taking acetaminophen and ibuprofen with minimal relief. The patient has no chronic medical conditions. She is on maternity leave from her engineering job. The patient has no drug allergies and is taking a daily prenatal vitamin. Temperature is 38.9 C (102 F), blood pressure is 110/70 mm Hg, and pulse is 100/min. Examination reveals the upper outer quadrant of the right breast to be erythematous, tender, and swollen but without fluctuance. The left breast has no erythema or tenderness. The patient returns to the office the next day with worsening symptoms. She has a family history of breast cancer and is very concerned about the pain. Temperature is 39.4 C (103 F), blood pressure is 100/70 mm Hg, and pulse is 114/min. Examination shows persistent swelling and erythema in the upper outer quadrant of the right breast in addition to a palpable area of induration. Which of the following is the best next step in management of this patient?

Question

A 25-year-old woman, gravida 1 para 1, comes to the office for evaluation of fever and right breast pain.  The patient is 2 weeks postpartum after an uncomplicated pregnancy and vaginal delivery.  She has been breastfeeding every 2-3 hours; however, the infant has had difficulty with latching due to the mother's inverted nipples.  Yesterday, the patient developed constant sharp pain in the side of her right breast as well as fever, chills, nausea, and body aches.  The pain is worsening, especially during breastfeeding.  She has been taking acetaminophen and ibuprofen with minimal relief.  The patient has no chronic medical conditions.  She is on maternity leave from her engineering job.  The patient has no drug allergies and is taking a daily prenatal vitamin.  Temperature is 38.9 C (102 F), blood pressure is 110/70 mm Hg, and pulse is 100/min.  Examination reveals the upper outer quadrant of the right breast to be erythematous, tender, and swollen but without fluctuance.  The left breast has no erythema or tenderness. The patient returns to the office the next day with worsening symptoms.  She has a family history of breast cancer and is very concerned about the pain.  Temperature is 39.4 C (103 F), blood pressure is 100/70 mm Hg, and pulse is 114/min.  Examination shows persistent swelling and erythema in the upper outer quadrant of the right breast in addition to a palpable area of induration.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bf8a_39b4_8f63_7984d3692c6e_MD0005_00 Breast abscess development is an uncommon complication of lactational mastitis but should be suspected in patients whose symptoms do not improve or worsen despite antibiotic therapy. The characteristic finding of an abscess is a focal area of fluctuance (wavelike motion on palpation, indicating pus collection). Induration (skin thickening from edema and inflammation) can occur in both mastitis and abscess. Ultrasound is the gold-standard modality for differentiating these conditions; it is quick, safe, inexpensive, and widely available, and it diagnoses abscess more accurately than physical examination. If an abscess is identified, ultrasound is also used to guide fine-needle aspiration under local anesthesia. (Choices A, D, and E) A breast infection that is refractory to treatment should prompt investigation for inflammatory breast cancer. A malignant mass is a rare but possible obstacle to milk drainage. On examination, accompanying clinical features include skin thickening, peau d'orange, and axillary lymphadenopathy. MRI is the imaging method of choice. Mammogram is not recommended for women age <30 as younger women tend to have denser breasts, which make this test more difficult to interpret. In addition, breast cancer is uncommon in women age <30, and mammography is associated with a higher rate of false-positive results. Palpation-guided, percutaneous fine-needle aspiration is the usual biopsy method for suspected cancer. (Choice C) Incision with drainage is the preferred treatment for most skin abscesses. However, this treatment for a breast abscess has increased risk of complications (eg, milk fistulas), slower recovery time, and a less desirable cosmetic outcome. Therefore, incision and drainage are reserved for abscesses that do not improve with antibiotics and fine-needle aspiration. Educational objective: Inadequately treated mastitis can progress to breast abscess. Induration and fluctuance on examination are evaluated by ultrasound to distinguish mastitis from an abscess. Treatment includes antibiotics and aspiration of fluid. References: Breast abscess: evidence based management recommendations. (http://www.ncbi.nlm.nih.gov/pubmed/24791941) Breast abscesses: evidence-based algorithms for diagnosis, management, and follow-up. (http://www.ncbi.nlm.nih.gov/pubmed/21997989)

A 25-Year-Old Woman, Gravida 1 Para 1, Comes to the Office