Six weeks after a spontaneous, uncomplicated term vaginal delivery, a 32-year-old woman, gravida 1 para 1, comes to the emergency department due to left breast pain. The patient first noticed pain and redness on her left breast a week ago. She has continued to breast feed her infant from the unaffected breast. The patient has no chronic medical conditions and her only medication is a daily multivitamin. Temperature is 38.3 C (101 F). Physical examination shows an area of erythema extending from the areola to the lateral edge of the left breast and surrounding a well-circumscribed, 4-cm area of fluctuance. Axillary lymphadenopathy is present. Which of the following is the best next step in management of this patient?

Question

Six weeks after a spontaneous, uncomplicated term vaginal delivery, a 32-year-old woman, gravida 1 para 1, comes to the emergency department due to left breast pain.  The patient first noticed pain and redness on her left breast a week ago.  She has continued to breast feed her infant from the unaffected breast.  The patient has no chronic medical conditions and her only medication is a daily multivitamin.  Temperature is 38.3 C (101 F).  Physical examination shows an area of erythema extending from the areola to the lateral edge of the left breast and surrounding a well-circumscribed, 4-cm area of fluctuance.  Axillary lymphadenopathy is present.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d9aa_3434_bc81_c5ef3c205291_MD0003_00 The patient has a breast abscess based on the presence of signs of mastitis (fever, localized erythema/pain) accompanied by a unilateral fluctuant, tender, palpable mass. Breast abscesses typically develop from untreated mastitis (as seen in this patient), which is typically due to incomplete emptying of the breast (eg, poor latch, alternating of breast and bottle feeds) and resultant milk stasis. In turn, persistent or severe mastitis can lead to a focal collection of purulent fluid (abscess). Mastitis and breast abscess are typically caused by Staphylococcus aureus, which enters the breast through nipple trauma (eg, chafing/blistering). The diagnosis of breast abscess is made clinically, but ultrasound may be required to differentiate severe mastitis from an abscess if a mass is deep within the tissue. Management includes drainage of the abscess with either needle aspiration (usually under ultrasound guidance) or incision and drainage. Empiric antibiotics against methicillin-sensitive S aureus (eg, dicloxacillin, cephalexin) are added for treatment of the surrounding mastitis. Continued breastfeeding is recommended for continued milk drainage. (Choice A) Breast binding is not recommended for breast engorgement, mastitis, or abscess because it increases pain and facilitates ductal blockage. (Choice B) Core needle and skin punch biopsies are indicated in the evaluation of inflammatory breast cancer, which can present similar to mastitis or abscess (eg, unilateral breast pain, axillary lymphadenopathy). However, patients typically have peau d'orange skin thickening and a solid (rather than fluctuant) mass. inflammatory breast cancer (Choice C) Ice packs and a supportive bra are indicated in the management of breast pain (ie, mastalgia). Patients with mastalgia have bilateral breast pain with no associated mass. (Choice E) Warm compresses and massage are indicated in the management of a clogged lactiferous duct, which can present with unilateral breast pain; however, the mass is typically located in the subareolar region and has no associated axillary lymphadenopathy. Educational objective: Breast abscesses present with a unilateral fluctuant, tender, palpable breast mass with fever, surrounding erythema/pain, and associated axillary lymphadenopathy. Management includes drainage (eg, needle aspiration) and empiric antibiotics (eg, dicloxacillin, cephalexin). References: Breast infection: a review of diagnosis and management practices. (http://www.ncbi.nlm.nih.gov/pubmed/30123878) Breast abscess: evidence based management recommendations. (http://www.ncbi.nlm.nih.gov/pubmed/24791941) Treatments for breast abscesses in breastfeeding women. (http://www.ncbi.nlm.nih.gov/pubmed/26279276)

Six Weeks After a Spontaneous, Uncomplicated Term Vaginal Delivery, a 32-Year-Old