A Clinical and Bacteriological Study of Breast Abscess In Female Patients

Mohammed Sabri Abdul-Razzaq, Wala’ Noori Berum,Hussein Noor Kadum
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Keywords : A Clinical and Bacteriological Study,Breast Abscess ,Female Patients,Arcanobacterium haemolyticum
Medical Journal of Babylon  11:2 , 2014 doi:1812-156X-11-2
Published :16 July 2014

Abstract

In this study, pus samples from seventy-one female patients admitted to the Breast Diseases Center, Hilla Teaching Hospital from September 2004 to June 2005 have been investigated. The samples have been classified into two groups: the first one included 53 lactating patients, ranging from 17 to 45 years , and the second did 18 non-lactating patients, where age ranged from 3 months to 57 years . The results have revealed a remarkably high incidence of breast abscess among lactating patients (74.6%).The high infection rate (54.7%) in the first group has been among those who were 20-29 years old, whereas in the second group ,the high infection rate (44.4%) has been among those who were 40-49 years old .It has also been found that the breast abscess is higher among multiparty women (66.2%). As for the first group ,the high incidence of breast abscess occurs mostly at the third month postpartum (45.3%) .It has Also been found that the incidence of subcutaneous abscess is higher than other types of breast abscess among the first group patients (52.8%) , whereas in the second group , the subareolar abscess is higher than other types (77.8%) . Furthermore, it has been found that the high incidence of breast abscess occurs in the left breast (60.56%) .Meantime , infection is higher among women of rural area (64.8%).The results of the bacteriological diagnosis have revealed that the species and percentage of bacteria isolated from the first group are Staphylococcus aureus (73.6%), Moraxella catarrhalis (5.7%), Streptococcus pyogenes (3.8%) and Staphylococcus epedermidis (1.9%). Whereas in the second group , the bacteria growth has been S.aureus (27.8%), Arcanobacterium haemolyticum (22.2%) and M.catarrhalis (11.1%) .

Introduction

A n abscess can be defined as an infected area of tissue that contains pus. The collection of pus is usually localized. The breast appears structurally and functionally to be relatively uncomplicated, but it is the site of a surprising broad array of pathological alterations; the breast abscess is one of these important and critical pathological alterations [1]. Breast abscess is more likely to develop in women when breast feeding a new baby especially if they have cracked nipples .This occurs as a sequel of mastitis .Women a patients do not immediately seek medical attention for treatment of puerperal mastitis . The breast abscess also occurs in non-lactating women but it is uncommon .This type of breast abscess must be differentiated from a rare form of breast cancer [2]. Breast abscess occurs mostly in women with infectious mastitis and It has reported that the incidence of the mastitis among lactating women is 2.5%; from those patients , only (11.1%) have developed breast abscess [4]. There are many species of pathogenic bacteria that can cause breast abscess, like S. aureus, S.epedermidis, S.pyogens and Bacteroides [5]. Most of the studies conducted on breast abscess have concluded that S.aureus is the most common cause of breast abscess. It has mentioned that S.aureus is the predominant cause of the breast abscess in both lactating and non-lactating patients [4,5]. Furthermore, it has said that the commonest cause of breast abscess in lactating patients is S. aureus, whereas in non-lactating patients the commonest cause is S.aureus and bacteroides [3,6]. The aim of this study is to assess the type and phase of presentation of breast abscess and isolation of aerobic bacteria associated with this disease.

Materials and methods

Patients
          From September 2004 to June 2005, seventy-one patients of breast abscess visited Breast Center at Hilla Teaching Hospital. Their ages ranged from 3 months to 57 years. All patients underwent the following investigations : ultrasound of the affected breast, fine needle aspiration (FNA) sent for aerobic bacteriological study . Out of the total number of patients twenty were on antibiotics, two were diabetic and one was suffering from sickle cell anemia.
Collection of Pus
           Fine needle aspiration was done for all patients to obtain the pus from localized abscess: the pus was collected in sterilized plastic tubes containing 5 ml of brain heart broth and incubated at 370C for 18 – 24 hr. before being plated on a screening media. Before FNA, the females breast were disinfected with 2% of iodine solution, then disinfected after area dryness with 70% ethanol [7].
Identification of Bacteria
             A single colony was taken from each primary positive culture growing on blood agar, nutrient agar and MacConky agar, identified by depending on its morphological characteristics such as shape, size, borders and texture , and then examined under microscope after staining it with Gram stain or other specific stains (such as Albert stain). After staining, the biochemical tests were done for each isolate to reach the final identification according to Bergy’s Manual for Determinative Bacteriology [8].




Results

In this study, seventy –one patients who have been suffering from breast abscess visited were investigated .Most of the patients were presented with classical features of the breast abscess (Table 1). These included mass (100%), pain (98.6%), fever (97.2%), and bright reddens (91.5%) . In lactating women , the high incidence of the breast abscess was noticed in the age group of the 20 – 29 years which constituted 54.7% of the patients and in the age group of 30 – 39 years which constituted 37.7% whereas the incidence rate decreased when the ages were less than 19 years and above 40 years (Table 3). On the other hand, in non lactating women, the high incidence rate was noticed in the age group of 40 – 49 years which constituted 44.4% of the patients (Table 3), which agreed with results obtained by [5] who observed that non-lactating breast abscess would encompass the third to the eight decades of life. These results likewise would agree with those obtained by [3,6] who mentioned that breast abscess in non-lactating women were very uncommon and it usually affected women older than 40 years. In addition, It referred that non lactation breast abscess often affected older women, when the super added bacterial infection in periductal mastitis could present as abscess [2,4]. However, the incidence of breast abscesses in non-lactating women between 20-29 years would be zero when compared to the lactated women. This study also showed that the high incidence rate occurred in women that had more than one child , representing 66.2% (Table 4.4). This finding might most likely be ascribed to recurrent mastitis which is a high risk factor of breast abscess. The recurrent mastitis is higher in multipara than primipara . So the breast abscess occurs in multipara more than primipara does. Besides the study has shown that the common type of breast abscess in lactating women is subcutaneous abscess which represents 45.3% of the patients, whereas in non lactating ladies the most common type is subareollar abscess which constitutes 77.8% of the patients (Table 5) . The high occurrence of the subareollar breast abscess in non lactating women was due to sequamous epithelial neoplasia with keratin plug or ductal extension with associated inflammation [7]. Besides, The associated pathogens were studied and divided into two groups; the first group was for single infecting microbes (Table 6). It included S.aureus, M. catarrhalis, S. pyogenes and S. epidermidis. The high incidence (73.6%) was of S.aureus, whereas the low incidence (1.9%) was of S.epidermidis. This study has shown that the breast abscess is due to monobacterial infection only, whereas the dibacterial infection has not been detected . Most bacterial isolates are related to the gram positive cocci and some gram negative cocci as shown in table [6] In the second group, however the associated pathogens could not be recovered. This group constituted 15% of the patients. The reasons of non-recoverable infection may be due to the following: a- Infection was nonbacterial .It was termed nonbacterial infection and caused by Cryptococcus or viruses [11]. b- Mastitis and breast abscess might be caused by Chlamydia, Mycoplasma, or Mycobacterium .That did not grow in culture conditions used in this study. c- Antibioma which resulted from uses of broad spectrum antibiotics would kill the bacteria and leave it as sterile pus [12].

Discussions

In this study, seventy –one patients who have been suffering from breast abscess visited were investigated .Most of the patients were presented with classical features of the breast abscess (Table 1). These included mass (100%), pain (98.6%), fever (97.2%), and bright reddens (91.5%) . In lactating women , the high incidence of the breast abscess was noticed in the age group of the 20 – 29 years which constituted 54.7% of the patients and in the age group of 30 – 39 years which constituted 37.7% whereas the incidence rate decreased when the ages were less than 19 years and above 40 years (Table 3). On the other hand, in non lactating women, the high incidence rate was noticed in the age group of 40 – 49 years which constituted 44.4% of the patients (Table 3), which agreed with results obtained by [5] who observed that non-lactating breast abscess would encompass the third to the eight decades of life. These results likewise would agree with those obtained by [3,6] who mentioned that breast abscess in non-lactating women were very uncommon and it usually affected women older than 40 years. In addition, It referred that non lactation breast abscess often affected older women, when the super added bacterial infection in periductal mastitis could present as abscess [2,4]. However, the incidence of breast abscesses in non-lactating women between 20-29 years would be zero when compared to the lactated women. This study also showed that the high incidence rate occurred in women that had more than one child , representing 66.2% (Table 4.4). This finding might most likely be ascribed to recurrent mastitis which is a high risk factor of breast abscess. The recurrent mastitis is higher in multipara than primipara . So the breast abscess occurs in multipara more than primipara does. Besides the study has shown that the common type of breast abscess in lactating women is subcutaneous abscess which represents 45.3% of the patients, whereas in non lactating ladies the most common type is subareollar abscess which constitutes 77.8% of the patients (Table 5) . The high occurrence of the subareollar breast abscess in non lactating women was due to sequamous epithelial neoplasia with keratin plug or ductal extension with associated inflammation [7]. Besides, The associated pathogens were studied and divided into two groups; the first group was for single infecting microbes (Table 6). It included S.aureus, M. catarrhalis, S. pyogenes and S. epidermidis. The high incidence (73.6%) was of S.aureus, whereas the low incidence (1.9%) was of S.epidermidis. This study has shown that the breast abscess is due to monobacterial infection only, whereas the dibacterial infection has not been detected . Most bacterial isolates are related to the gram positive cocci and some gram negative cocci as shown in table [6] In the second group, however the associated pathogens could not be recovered. This group constituted 15% of the patients. The reasons of non-recoverable infection may be due to the following: a- Infection was nonbacterial .It was termed nonbacterial infection and caused by Cryptococcus or viruses [11]. b- Mastitis and breast abscess might be caused by Chlamydia, Mycoplasma, or Mycobacterium .That did not grow in culture conditions used in this study. c- Antibioma which resulted from uses of broad spectrum antibiotics would kill the bacteria and leave it as sterile pus [12].

Conclusions

The results of this study confirmed that Breast Abscess incidence was high among lactating women and Gram positive bacteria was predominant as a causative agents for this disease.

References

1-Blumstein, H.; Rontal, A.K.; Brown, D.F.; Talavera, F. and Alder, J.(2003). Breast abscess and masses.J. Hum. Lact., 20(2): 153 – 58.
2-Denar, C. and Inan, A. (2003). Breast abscess in lactating women. World J. Surg., 27 (2) : 130 – 33.
3-Fetherston, C. (2001). Mastitis in lactating women: Physiology or pathology? Breast feed. Rev., 9 (1) : 5 – 12.
4-Foxman, B.J.; Darcy , H.; Gillespie, B.; Bobo, J.K. and Schwartz, K. (2002). Lactation mastitis: Occurrence and medical management among 946 breast feeding women in the United States. Am. J. Epidemiol., 155 (2) : 103 – 14.
5-Hale, T. (2000). Medication and mother milk, 9th Ed., pharmasoft Medical Publishing, Texas, pp: 345 – 6.
6-Howard , A. (2005). Wake Forest University School of Medicine “Breast abscess and masses” . At Medicine .Com. Inc. Accept in 27 October 2005 .
7-Jay, R.H. and Marce, E. (1998). Diseases of the Breast, 1 st ed., Lippincot Williams & Wilkins Co., Baltimore, U.S.A.
9-Kinlay, J.R. ; O’connell, D.L. and Kinlay, S. (2001) .Risk factors for mastitis in breastfeeding women: result of a prospective cohort study . Aust. N. Z. J. Public Health, 25 (2) : 115 – 20 .
8-Holt, J.G.; Krieg, N.R.; Sneath, P.H.; Staley, J.T. and Williams, S.T. (1994). Bergeey’s Manual of Determinative Bacteriology. 9th ed., Williams and Wilkins, Baltimore, U.S.A.
10-Thomsen, A.C. (1982). Infectious mastitis and occurrence of antibody-coated bacteria in milk. Am. J. Obstet. Gynecol., 144 (3): 350 – 51 .
11-Marchant, D.J. (2002). Inflammation of the breast. Obstet. Gynecol. Clin. Nor. Am., 29 (1): 89 – 102 .
12-Michie, C.; Lockie, E and Lyna, W. (2003). The challenge of mastitis. Arch. Dis. Child., 88: 818 – 21 .


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