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Mastitis is the inflammation of the mammalian mammary gland (breast in primates, udder in other mammals). It is called puerperal mastitis when it occurs in lactating mothers and non-puerperal otherwise. Mastitis can rarely occur in men. Inflammatory breast cancer has symptoms very similar to mastitis and must be ruled out.
Popular usage of the term mastitis varies by geographic region. Outside the US it is commonly used for puerperal and nonpuerperal cases, in the US the term nonpuerperal mastitis is rarely used.
Chronic cystic mastitis, also called fibrocystic disease, a condition rather than a disease, is characterized by noncancerous lumps in the breast.
American slang: here mastitis usually refers to puerperal (occurring to breastfeeding mothers) mastitis with symptoms of systemic infection. Lighter cases of puerperal mastitis are often called breast engorgement.
Names for non-puerperal mastitis are not used very consistently and include Mastitis, Subareolar Abscess, Duct Ectasia, Periductal Inflammation, Zuska's Disease and others.
In this wikipedia article mastitis is used in the original sense of the definition as inflammation of the breast with additional qualifiers where appropriate.
Mastitis is also a very common condition in Veterinary medicine.
Additional recommended knowledge
Caused by the blocking of the milk ducts while the mother is lactating (see breastfeeding). It can cause painful areas on the breasts or nipples and may lead to a fever or flu-like symptoms. Mastitis can be discerned from simple blockages by the intensity of pain, heat emanating from the area, redness and fever in the mother. In some cases the fever can become severe, requiring antibiotics; ten percent of cases develop into abscesses that need to be drained surgically.
Massage and the application of heat can help prior to feeding as this will aid the opening of the ducts and passageways. A cold compress may be used to ease the pain when not wanting to lose the milk, though it is most appropriate to reduce the levels of milk contained. For this reason it is also advised that the baby should frequently feed from the inflamed breast. However, the content of the milk may be slightly altered, sometimes being more salty, and the taste may make the baby reject the breast at the first instance.
The presence of cracks or sores on the nipples increases the likelihood of infection. Tight clothing or ill-fitting bras may also cause problems as they compress the breasts. The most common infecting organism is Staph. aureus, and babies carrying the organism in their noses are more likely to give it to their mothers; the clinical significance of this finding is still unknown, but theoretically, removing carriage from the nursing infant's nose may help prevent recurrence.
In severe cases it may be required to stop lactation and use lactation inhibiting medication.
A study of women attending two lactation/breastfeeding conferences concluded that management and control of stress and fatigue is important in preventing mastitis. 
The term Nonpuerperal mastitis describes all inflammatory lesions of the breast except inflammatory breast cancer and skin related conditions like dermatitis and foliculitis. This article includes description of mastitis as well as various kinds of mammary abscesses.
Most patients are women of reproductive age but mastitis beyond the age of 60 is not uncommon. Rarely occurs in newborn children (Mastitis neonatorum) or prepubertal children.
So called pre-pubertal mastitis can occur shortly before or during the first stages of puberty of both boys and girls with very mild symptoms and resolves without intervention.
Symptoms of nonpuerperal mastitis
Systemic (flu like) symptoms like in puerperal mastitis are rare.
Special forms of mastitis like subareolar abscess can show rare symptoms like nipple retraction and skin dimpling.
Mammography and symptoms alone never allow reliable exclusion of breast cancer. Mastitis may also mimic several typical signs of malignancy on mammography.
Depending on appearance, symptoms, aetiological assumptions and histopathological findings a variety of terms has been used to describe mastitis and various related aspects.
Aetiology and Pathogenesis
Most clinically significant cases present as inflammation of the ductal and lobular system (galactophoritis) and possibly the immediately surrounding tissue.
Secretory stasis is the cause of nonpuerperal mastitis in about 80% of cases (Lanyi 2003). The retained secretions can get infected or cause inflammation by causing mechanical damage or leaking the lactiferous ducts. Autoimmune reaction to the secretions may be also a factor.
Several mechanisms are discussed throughout literature that may cause or predispose this (Lanyi 2003, Peters & Schuth 1989, Goepel & Pahnke 1991, Krause et al 1994).
About 25% of patients may be hyperprolactinemic and significant coincidence with Fibercystic Condition and thyroid anomalies has been documented (Peters & Schuth 1989, Goepel & Pahnke 1991). Up to 50% of patientes experience transient hyperprolactinemia possibly caused by the inflammation or treatment and most had abnormally high Prolactin reserve (Goepel & Pahnke 1991).
Prolactin, IGF-1 and TSH are important sytemic factors in galactopoesis, their significance in secretory disease is not documented but it has been asserted that the mechanisms of secretory disease and galactopiesis are closely related (Lanyi 2003).
Permeability the of the alveolar and ductal epithelia is mostly controlled by tight junction regulation and is closely linked to galactopoiesis and possibly secretory disease. The tight junctions are regulated by a multitude of systemic (prolactin, progesterone, glucocorticoids) and local (intramammary pressure, TGF-beta, osmotic balance) factors (Nguyen & Neville 1998)
Tobacco smoking appears to be an important factor in the aetiology of squamous metaplasia of lactiferous ducts, around 90% of patients with this condition are smokers. Current smokers have the worst prognosis and highest rate of recurrent abscesses.
Acromegaly may present with symptoms of nonpuerperal mastitis.
Diabetes and many conditions with suppressed immune system can cause various infections of the breast and mastitis. Such conditions often present with inflammation of peripheral tissue and exotic infections.
Nipple piercings pose a risk due to bacterial infection following the injury and hormonal stimulation by the piercing (Jacobs et al 2003, Modest & Fangman 2002, Demirtas et al 2003).
Treatment according to presumed cause, diagnosis and treatment of underlying condition is very important.
Prolactin inhibiting medication has been shown to be most effective and reduce risk of recurrence (Goepel & Pahnke 1991, Krause et al 1994, Stauber & Weyerstrahl 2005, Petersen 2003, Goerke et al 2003).
Antibiotics should be given in addition to prolactin inhibiting medication if there are clear signs of infection.
Granulomatous mastitis has been treated with some success by a combination of steroids and Prolactin inhibiting medication (Krause et al 1994).
More exotic treatments for nonpuerperal mastitis that have been mentioned to show at least some efficiacy include local and systemic Progestins or Progesteron (Goepel & Pahnke 1991), antidiuretics, Vitex Agnus Castus extract and Danazol.
NSAIDs are being used to treat symptoms of the inflammation, however it must be considered that these medicaments also affect pituitary function and tend to increase Prolactin and IGF-1 levels (Caviezel et al 1983).
Many variants of surgical procedures such as duct resection have been tried to reduce the risk of recurrent subareolar abscesses. So far the success rates are limited and conservative treatment seems preferable where possible (Petersen 2003, Hannavadi et al 2005).
Approximately 30% of cases develop chronic or recurring mastitis requiring long term or indefinite treatment with Prolactin inhibiting medication (Goerke et al 2003).
Breast cancer and mastitis
Lifetime risk for breast cancer is significantly reduced for women who were pregnant and breastfeeding. Mastitis episodes do not appear to influence lifetime risk of breast cancer.
Mastitis does however cause great difficulties in diagnosis of breast cancer and delayed diagnosis and treatment can result in worse outcome.
Breast cancer may coincide with mastitis or develop shortly afterwards. All suspicious symptoms that do not completely disappear within 5 weeks must be investigated.
Breast cancer incidence during lactation is assumed to be the same like in controls. Diagnosis during lactation is particularly problematic, often leading to delayed diagnosis.
Some data suggests that breast cancer incidence is increased following episodes of nonpuerperal mastitis and special care is required for followup cancer prevention screening.
A very serious type of breast cancer called inflammatory breast cancer presents with similar symptoms as mastitis. It is the most aggressive type of breast cancer with the highest mortality rate. Case reports indicate that inflammatory breast cancer symptoms can flare up following injury or inflammation making it even more likely to be mistaken for mastitis. Because inflammatory breast cancer is mostly EGF positive this may be a reaction of a preexisting asymptomatic cancer to local cytokine stimulation following the normal injury or inflammatory response.
References for nonpuerperal mastitis
Many of those are in German, no usable English language literature known.
Categories: Inflammations | Breast
|This article is licensed under the GNU Free Documentation License. It uses material from the Wikipedia article "Mastitis". A list of authors is available in Wikipedia.|