Ms. Johnson is a 39 yo G4P4 who has received all of her prior care with you. On chart review, you see that she has no PMH/PSH, her only med is PNV, and she smokes 1-2 cigarettes per day. She delivered a healthy baby girl 6 months ago and has been breastfeeding; however she has been supplementing/transitioning to formula since she returned to work 6 weeks ago. She presents to Ob/Gyn Clinic today with 8 weeks of progressively worsening left-sided breast pain that is constant, aching, and 6/10 severity. The pain is associated with an expanding area of redness, warmth, swelling, and nipple discharge, itching, and deformity. She admits to taking "my boyfriend's leftover antibiotics" for the past 7 or 8 days while waiting for this appointment; When she calls her boyfriend and asks him to read the bottle, she states that she has been taking Bactrim 160/800mg twice a day. Her temperature is 99.9, VS otherwise normal. On physical exam, her left breast is tender to palpation, with mild thickening of the breast tissue, slight nipple inversion, and peau d'orange appearance. There is no palpable mass or fluctuant area. Her right breast/nipple appear normal, although her right breast is notably smaller. WBC = 9.
Which of the following is the most likely diagnosis? What imaging would you do?
A-mastitis
B-breast abscess
C-inflammatory breast cancer
set up each as a link with answer C correct
A-mastitis:
No, lactational mastitis is characterized by localized breast tenderness and erythema, fever (> 101F), leukocytosis, malaise, fatigue, headaches, and response to antibiotics. Ms. Johnson meets none of these criteria. While we cannot be sure that the antibiotics this patient has been taking haven't expired, it appears as though she has been taking an appropriate regimen for treating lactational mastitis; and while the recommended course is 10 days, she should have felt some improvement in symptoms (not continued worsening) after 48 hours. Nipple deformity along with peau d'orange skin changes are very suggestive of breast malignancy, especially inflammatory carcinoma
B-breast abcess-
No, although breast abscess classically occurs when the breastfeeding mother returns to work, Ms. Johnson's breast symptoms started 2 weeks before she returned to work. Also by definition, an abscess is a collection that could potentially be drained. In Ms. Johnson's case, there was no palpable mass or fluctuant area on exam. Nipple deformity along with peau d'orange skin changes are very suggestive of breast malignancy, especially inflammatory carcinoma
C-inflammatory breast cancer-
Yes, nipple deformity, palpable thickening of the breast tissue, along with peau d'orange skin changes, and rapid onset of signs/symptoms within 2-3 months are very concerning for inflammatory carcinoma. 3% of women with breast cancer are pregnant/lactating, so diagnostic workup should not be delayed.
OB GYN CASE 2