A 39-year-old woman, gravida 2 para 2, comes to the office for evaluation of increasing malaise. The patient has been exclusively breastfeeding her 3-month-old infant. For the past week, she has been taking dicloxacillin due to redness and pain in her right breast. Over the past few days, the patient has developed increasing malaise and a low appetite. She has had no nausea, diarrhea, or headache. The patient has no chronic medical conditions and takes no other daily medications. Her mother had breast cancer at age 54. Temperature is 37.7 C (99.9 F), blood pressure is 124/68 mm Hg, and pulse is 98/min. Both breasts have moderate engorgement. There is linear nipple cracking bilaterally. The right breast has tender nodularity, but the erythema has improved since last week's examination. The remainder of the physical examination is unremarkable. Which of the following is the best next step in management of this patient?

Question

A 39-year-old woman, gravida 2 para 2, comes to the office for evaluation of increasing malaise.  The patient has been exclusively breastfeeding her 3-month-old infant.  For the past week, she has been taking dicloxacillin due to redness and pain in her right breast.  Over the past few days, the patient has developed increasing malaise and a low appetite.  She has had no nausea, diarrhea, or headache.  The patient has no chronic medical conditions and takes no other daily medications.  Her mother had breast cancer at age 54.  Temperature is 37.7 C (99.9 F), blood pressure is 124/68 mm Hg, and pulse is 98/min.  Both breasts have moderate engorgement.  There is linear nipple cracking bilaterally.  The right breast has tender nodularity, but the erythema has improved since last week's examination.  The remainder of the physical examination is unremarkable.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d9aa_f785_bc81_2309cbe5a72a_MD0003_00 Lactational mastitis is common in breastfeeding patients and typically presents with flu-like symptoms (eg, fever, malaise) and unilateral breast erythema and pain. Empiric treatment is with either dicloxacillin (as in this patient) or cephalexin, both of which are effective against the most common pathogen, methicillin-sensitive Staphylococcus aureus (MSSA). Most patients respond quickly (within 1-2 days) to antibiotic therapy; however, some patients can retain infected, stagnant milk (typically due to incomplete emptying) that can lead to a focal collection of purulent fluid (ie, breast abscess). Because the abscess forms a walled-off cavity, it is less susceptible to antibiotic penetration. Therefore, patients may have improvement of overlying skin erythema (as seen in this patient), but no improvement in systemic symptoms (eg, malaise, appetite) with antibiotics. The diagnosis of breast abscess can be made clinically, but an ultrasound is performed to differentiate severe mastitis from an abscess in patients with tender breast nodularity but no palpable discrete, fluctuant mass. Treatment is with ultrasound-guided needle aspiration or surgical incision and drainage. Continued breastfeeding is recommended for milk drainage. (Choice A) Fluconazole may be indicated in patients with signs of candidal mastitis, such as a shiny or flaky unilateral areolar rash (rather than bilateral nipple cracking, which indicates breastfeeding trauma). Candidal mastitis also typically causes burning or shooting breast pain out of proportion to the examination. None of these are present in this patient. (Choice B) Topical corticosteroids can be used to treat contact dermatitis, which commonly presents with skin erythema. However, dermatitis does not cause a palpable, tender breast nodule or systemic symptoms (eg, fatigue, low appetite). (Choice C) Changing the antibiotic to cephalexin is not indicated because dicloxacillin (beta-lactam) and cephalexin (first-generation cephalosporin) have similar coverage for MSSA. Breast abscesses require drainage, and dicloxacillin should be continued in this patient after drainage to treat the surrounding lactational mastitis. (Choice E) Full-thickness skin biopsy may be indicated in patients with suspected inflammatory breast cancer (IBC), which can present with similar symptoms (eg, unilateral breast pain, erythema, warmth). Unlike this patient with improved erythema, those with IBC typically have classic skin thickening with dimpling (peau d'orange). Educational objective: Patients with lactational mastitis who do not improve with antibiotic therapy require breast ultrasound to evaluate for breast abscess. Management is with abscess drainage (eg, ultrasound-guided needle aspiration). References: Breast abscesses: evidence-based algorithms for diagnosis, management, and follow-up. (http://www.ncbi.nlm.nih.gov/pubmed/21997989) Mastitis while breastfeeding: prevention, the importance of proper treatment, and potential complications. (http://www.ncbi.nlm.nih.gov/pubmed/32707832)

A 39-Year-Old Woman, Gravida 2 Para 2, Comes to the Office