1. Index case 1 Year 2 Michaelmas term
A painful breast
Index case 1
Year 2 Michaelmas term

2. The 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.

3. Last 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.

4. On 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.

5. There are palpably enlarged nodes in
the right axilla.
The left breast and axilla are normal.

7. What is the differential diagnosis?

8. What is the differential diagnosis?
Acute breast infection -
Cellulitis ?
Abscess?

9. What is the differential diagnosis?
Acute breast infection -
Cellulitis ?
Abscess?
Periductal mastitis

10. Periductal mastitis

11. What is the differential diagnosis?
  Acute breast infection –Cellulitis, Abscess
Peri-ductal mastitis (smoking related)
Inflammatory carcinoma
Fat necrosis – (can be spontaneous but usually related to trauma)
Sting- wasp? Bee? (ask - it may be as simple as this!)

12. Bee stings

13. Which is most likely and why?

14. Which is most likely and why?
Mastitis/abscess

15. Which is most likely and why?
Mastitis/abscess
Breast feeding; diabetes

16. How would you manage this case?

17. Triple assessment History and examination Imaging
Tissue and or bacteriological diagnosis

18. Breast abscess: ultrasound useful for detecting fluid cavities

19. Mammography non-specific and very painful

20. Tissue/bacteriology
Histology
Milk culture
Blood culture

21. Likely organisms Staphylococcus aureus Escherichia coli MRSA
Pseudomonas aeruginosa

22. What is the difference between cellulitis and an abscess?

23. cellulitis
diffuse inflammatory process with little focal necrosis and pus. Inflammatory cells present in the tissues- neutrophils predominate with tissue oedema.

24. cellulitis

25. abscess
A cavity containing pus surrounded by an inflammatory response.
Pus- neutrophils, bacteria and necrotic debris

26. Treatment of mastitis

27. Treatment of mastitis
Early treatment with antibiotics to prevent abscess development
- flucloxacillin
-consider IV with diabetes or very unwell/dehydrated

28. Continue to breast-feed?

29. Continue to breast-feed?
Yes- if can manage
Most antibiotics OK to use in breast-feeding
Bacteria killed in baby’s stomach
May prefer to feed from normal side

30. What if there is an abscess?

31. What if there is an abscess?
Small abscess can be drained with a needle under LA
Large abscess may require open drainage LA or GA

32. Mastitis a good example of acute inflammation

33. Features of acute inflammation
Vascular changes: blood flow
Vascular changes: vessel wall leaks
Cellular changes

34. Vascular changes: blood flow
Transient vasoconstriction then vasodilation
Increased in arteriolar and venous hydrostatic pressure
Leakage of fluid and protein into extravascular space

35. Vascular changes: vessel wall leaks
Gaps develop in endothelium of venules
Cytoskeletal reorganisation and transcytosis of vacuoles in endothelial celles
Direct damage of cell wall (e.g in burns)
Other leakage from leukocytes
Angiogenesis: new vessels leak

36. Cellular changes
Margination, rolling adhesion of white cells to vessel wall.
Movement of leukocytes into tissues to destroy bacteria
Helped by stasis, cytokines, diapedesis, chemotaxis

37. Cytokines Local chemical mediator 4 groups:
Selectins stimulated by histamine
Immmunoglobulins
Integrins
Mucin-like glycoproteins

38. diapedesis
Movement of white cells through gaps between cells (mainly venules; capillaries in lung)
Use collagenases to pierce basement membrane
Variation in cell type and time of onset

39. In acute bacterial infection:
Leukocytes 6-24 hours
Monocytes hours
Lymphocytes> 72 hours

40. Can vary with type of infection/injury:
Pseudomonas neutrophils 2-4 days
Viral infection: lymphocytes predominate
Allergic reaction: eosinophils predominate

41. chemotaxis Attraction of leukocytes to bacteria
E.g anaphylotoxins produced by interaction of complement, antibodies and bacterial antigens

42. An activated leukocyte can:
Move. Chemotaxis causes release of calcium and contractile elements in leukocyte. Pseudopods
Produce poison: arachidonic acid metabolites; degranulation of lysosomal enzymes
Stick to endothelium
Recognise bacteria through opsonins
Phagocytose
Kill e.g with H2O2

43. Unfortunately this process also causes localised damage to tissue
Unfortunately this process also causes localised damage to tissue. This can cause disease

44. Examples of acute inflammatory disease?

45. Examples of acute inflammatory disease?
Pelvic inflammatory disease
Puerperal sepsis
Septic shock
Glomerulonephritis
Asthma
Transplant rejection
Atherosclerosis
arthritis

46. If there is one thing to remember about acute inflammation it would be:

47. The neutrophil