Recurrent Breast Abscess

Recurrent breast abscess is the return of a breast abscess at the same or a different site on two or more occasions after treatment. It results from incomplete drainage, a persistent duct fistula, smoking, diabetes, HIV, chronic infection (tuberculosis, fungal), granulomatous mastitis, hidradenitis suppurativa, foreign bodies and an underlying cancer. It matters because repeated infection destroys breast tissue and an undiagnosed cancer or tuberculosis can be missed.

• Risk factors: smoking, diabetes, HIV, previous abscess, incomplete drainage or short antibiotic course, nipple piercing, obesity, immunosuppression, periductal mastitis.
• A fistula to the areola is the commonest cause in non lactating women.
• Biopsy is needed to exclude tuberculosis, granulomatous mastitis and cancer.

Women have repeated painful breast lumps, discharge from a sinus, nipple retraction and scarring, with fever during each episode. The skin over the breast may be thickened, scarred and ulcerated.

• Chronic discharging sinus or fistula at the areola margin or elsewhere.
• Multiple scars from previous drainage.
• Differential diagnosis: persistent duct fistula, periductal mastitis, subareolar abscess, granulomatous mastitis, tuberculous mastitis, fungal infection, hidradenitis suppurativa, infected cyst, foreign body, breast cancer, inflammatory breast cancer.
• Complications: breast deformity, chronic pain, sepsis, delayed cancer diagnosis, repeated surgery, depression, loss of breastfeeding ability.

The approach is to find the underlying cause through imaging, culture and tissue.

• Examination of the breast, areola, nipple and axillae; photograph of scars and sinuses.
• Ultrasound of the breast and sinus tract; MRI to show a deep track or extent; mammography if age is 40 years or above.
• Pus and tissue culture (aerobic, anaerobic, mycobacterial, fungal), Ziehl-Neelsen stain, Xpert MTB/RIF; core or excision biopsy of the wall or any mass for histology.
• Glucose, HbA1c, HIV test and CD4 count, full blood count, chest X-ray.

The principle is complete drainage, culture guided antibiotics, treatment of the underlying cause, and surgical excision of the diseased duct or fistula.

• Supportive: stop smoking; control glucose; nutrition; dressing of sinuses; remove nipple jewellery; analgesia; counselling on recurrence.
• Pharmacological: acute infection: amoxicillin-clavulanate 625 mg oral 8-hourly for 10 to 14 days, or cefalexin 500 mg oral 6-hourly plus metronidazole 400 mg oral 8-hourly for 10 to 14 days; severe infection or methicillin-resistant Staphylococcus aureus: vancomycin 15 mg/kg IV 12-hourly, or clindamycin 450 mg oral 8-hourly; tuberculosis: rifampicin 10 mg/kg (usual 600 mg) plus isoniazid 5 mg/kg (usual 300 mg) plus pyrazinamide 25 mg/kg (usual 1500 mg) plus ethambutol 15 mg/kg (usual 1200 mg) oral once daily for 2 months, then rifampicin plus isoniazid for 4 months, with pyridoxine 25 mg oral once daily; fungal infection: fluconazole 400 mg oral once daily for 6 weeks or longer; granulomatous mastitis: prednisolone 0.5 mg/kg oral once daily (usual 30 to 40 mg) for 4 weeks then tapered over 8 to 12 weeks; paracetamol 1 g oral 6-hourly (maximum 4 g in 24 hours).
• Procedures: ultrasound guided aspiration or incision and drainage with a wick; total duct excision with fistulectomy once infection has settled (4 to 6 weeks); wide excision of chronic abscess cavity with biopsy; mastectomy rarely, for extensive destruction or cancer.
• Special groups: women with diabetes need insulin to keep glucose below 10 mmol/L; women with HIV who are on rifampicin take dolutegravir 50 mg oral twice daily; smokers need support to stop before surgery.
• Red flags: hard fixed mass, bloody nipple discharge, skin thickening with peau d'orange, axillary nodes that are hard, weight loss with night sweats, failure to heal after 6 weeks, fever with systemic upset.
• Follow-up: review at 1 week and 4 weeks; ultrasound at 4 weeks; surgical review at 4 to 6 weeks; review at 3 months and 6 months; breast examination and imaging yearly.