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Case 12: Pain and lump in the breast

A 24 year old woman has been breast feeding for 2 months. She now presents with a painful, red mass in the lower outer quadrant of her left breast.

1. What is the likely diagnosis?

Lactational breast abscess

2. What advice would you give her about breast feeding?

Continue feeding to encourage drainage of the breast. An abscess develops when there is a relative obstruction to flow from a lobule of the breast related to inspissated material in the ducts. Organisms most likely ascend the duct after gaining entry through the nipple which may be cracked or damaged from feeding.
The baby will not be harmed by feeding from this breast and should be fed from the effected side first. If feeding is too painful then the breast should be manually expressed.

3. Outline you management plan for this woman

After a thorough history and examination the next investigation should be an ultrasound to sonfirm the presence and size of an abscess. Differentiation from mastitis without abscess may be difficult clinically. Heat packs and massage, particularly in a warm shower, may also help. Analgesia and antibiotics are usually required.
Unless the overlying skin is thin and necrotic it is not usually necessary to incise and drain a breast abscess. Rather it is preferable to aspirate it with a large bore needle often with US guidance. This procedure may need to be repeated on a daily basis until the abscess resolves but creates less risk of a milk fistula and cosmetic deformity.
The possibility of an inflammatory cancer always needs to be considered although this is unlikely in a lactating woman. As a result she should be followed up with clinical examination and imaging after resolution of the abscess.