Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 15  |  Issue : 1  |  Page : 20-23

Management challenges of complicated lactational breast abscess in a tertiary health facility in a resource-constrained environment


Department of Surgery, Federal Medical Center, Birnin Kebbi, Kebbi State, Nigeria

Date of Web Publication26-Aug-2019

Correspondence Address:
Dr. Eguono Erhinyaye Omoyibo
MBBS, FWACS, Consultant Plastic Surgeon, Department of Surgery, Federal Medical Centre, P.M.B. 1126, Birnin-Kebbi, Kebbi State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njps.njps_15_18

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  Abstract 


Background: Lactational breast abscess, if not promptly and appropriately treated, can become complicated with associated destruction of breast skin and tissue that may necessitate breast resurfacing or reconstruction. The study is aimed at highlighting management challenges of patients who presented with complicated lactational breast abscess to a tertiary health facility in a resource-constrained environment. Patients and Method: A retrospective review of patients who presented with complicated lactational breast abscess to a tertiary health facility in northwest Nigeria from April 2015 to March 2017 was carried out. Patients were identified using the hospital admission records and appropriate data were retrieved from their case notes and analyzed. Results: A total of 17 patients were included in the study and 10 (58.8%) were in the age range 21 to 30 years. Nine (52.9%) patients presented in the puerperal period and 10 (58.8%) patients were multiparous. Left breast was predominantly affected accounting for 10 (58.8%) cases whereas there was bilateral breast involvement in four (23.5%) patients. Sixteen (94.1%) patients presented after the symptoms have started for more than a week. Four (23.5%) of the patients had necrotizing infection. Six (35.3%) patients had surgical intervention for breast resurfacing or breast reconstruction whereas 11 (64.7%) patients declined surgery due to financial constraint. Conclusion: Complicated breast abscess is not uncommon among lactating women in our environment due to late presentation resulting from illiteracy, poverty, and cultural practice of seeking alternative medical practice and its management is challenging to the surgeon partly due to financial constraint for patients’ treatment.

Keywords: Breast abscess, complicated, management challenges


How to cite this article:
Ibrahim MH, Omoyibo EE. Management challenges of complicated lactational breast abscess in a tertiary health facility in a resource-constrained environment. Nigerian J Plast Surg 2019;15:20-3

How to cite this URL:
Ibrahim MH, Omoyibo EE. Management challenges of complicated lactational breast abscess in a tertiary health facility in a resource-constrained environment. Nigerian J Plast Surg [serial online] 2019 [cited 2019 Sep 16];15:20-3. Available from: http://www.njps.org/text.asp?2019/15/1/20/265406




  Introduction Top


Mastitis, which is an inflammation of the breast, can occur during lactation and when left untreated or is poorly treated can result in lactational breast abscess, which is a collection of pus within the breast tissue.[1],[2] Most breast infections occur within the first or second month after delivery or at the time of weaning.[3],[4] Clinical presentation of lactational breast abscess usually includes fever, chills, malaise, pain in the affected breast, as well as the presence of redness, swelling, and tenderness in an area of the breast or a well-defined fluctuant lump in the affected breast. However, a mass is not always palpable, especially if it is located deep within a large breast.[4],[5] Early diagnosis of lactational breast abscess and appropriate intervention are vital for preservation of breast tissue. Treatment of breast abscess can be accomplished with incision and drainage or ultrasound-guided needle aspiration alongside with use of appropriate antibiotics.[6],[7],[8],[9] However, delayed presentation can result in the lactational breast abscess becoming complicated with associated destruction of breast skin with or without other breast tissues. In our practice environment, patients with lactational breast abscess usually present late and possible reasons include illiteracy, lack of awareness, low socioeconomic status, and the practice of seeking alternative medical treatment. This study is aimed at presenting our experience with managing patients with complicated lactational breast abscess in a tertiary health facility in northwest of Nigeria. For the purpose of this study, complicated lactational breast abscess is considered as lactational breast abscess associated with loss of breast skin with or without the breast tissue and requiring skin resurfacing with or without breast tissue reconstruction.


  Patients and method Top


The study is a retrospective, descriptive study of patients who presented with complicated lactational breast abscess to the Plastic and Reconstructive Surgery Unit of the Federal Medical Centre, Birnin Kebbi, northwest Nigeria from April 2015 to March 2017. The Federal Medical Centre Birnin Kebb, Kebbi State is a tertiary health referral center for burn, plastic, and reconstructive surgery and other specialties and serves patients living in the state and neighboring villages and towns of Sokoto State, Niger State, and Niger Republic. The patients were identified using the admission records of the Female Surgical Ward and the records of the of Health Information Management Department of the hospital. Appropriate data were retrieved from the patient’s case notes and analyzed accordingly.


  Results Top


Within the study period, a total of 17 patients who presented with complicated lactational breast abscess were identified. The age range was from 17 to 40 years with a mean of 25.1 years. Patients in the 21 to 30-year age range were predominantly affected accounting for 10 (58.8%) of the cases. Ten (58.8%) of the patients were multiparous. There was left breast involvement in 10 (58.8%) cases and bilateral breast involvement in four (23.5%) cases. Nine (52.9%) patients presented within the puerperal period whereas two (11.8%) patients presented during pregnancy, one at 9 months of gestation and the other at 6 months of gestation. Seven (41.2%) patients received local remedies before presentation at the hospital. The local remedies comprise mainly of local incision and drainage with hot metal and application of herbal concoction to the breast wound. There was complete loss of the nipple–areolar complex in seven (41.2%) cases and partial loss in one (5.9%) case. [Table 1] shows the demographic and clinical characteristics of the patient. [Figure 1] (A and B) and [Figure 2] show the photographs of two of the patients seen.
Table 1 Demographic and clinical characteristics of the patients

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Figure 1 (A) Before surgical reconstruction. There is loss of the nipple–areolar complex. (B) After surgical reconstruction using latissimus dorsi musculocutaneous flap.

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Figure 2 Postdebridement for necrotizing infection in a lactating young woman. Declined skin grafting for resurfacing due to financial constraint.

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  Discussion Top


Lactational breast abscess is a complication of poorly treated mastitis.[2] It can be prevented by early recognition and prompt treatment of lactational mastitis with appropriate antibiotics. However, when lactational breast abscess occurs, treatment can be accomplished with incision and drainage or by needle aspiration (preferably ultrasound guided) alongside use of appropriate antibiotics. Early recognition and appropriate treatment of breast abscess will result in resolution of the breast abscess without any grievous sequelae. However, delayed presentation and treatment can lead to destruction of breast skin and tissue requiring skin resurfacing with or without breast tissue reconstruction. In resource-constrained countries like ours, patients often present late due to illiteracy and low socioeconomic status. Patients are often neglected or seek alternative treatment and show up after failed treatment from local remedies and quacks. In this study, 16 (94.1%) patients presented after more than 1 week of onset of symptoms of painful breast swelling and fever. In nine (52.9%) patients, the breast infection occurred in the puerperal period, which is a period when nursing mothers have challenges in initiating breast feeding and therefore are at risk of lactational mastitis and breast abscess. The age range 21 to 30 years was predominantly affected accounting for 10 (58.8%) cases. This is similar to the findings by Abdul-Razzaq and Kadum.[10] Left breast was predominantly affected accounting for 10 (58.8%) cases that is similar to the finding of 60% of breast abscess in the left breast by Karvande et al.[11] Four (23.5%) patients with necrotizing type of infection had blood transfusion due to low hematocrit level at presentation. This reflects the severity of the disease when associated with necrotizing fascitis and the need for more attention in the care of such patients. Four (23.5%) patients had split thickness skin grafting for breast resurfacing whereas two (11.8%) patients had latissimus dorsi musculocutaneous flap reconstruction of the breast defects. There was complete loss of the nipple–areolar complex in seven (41.2%) cases and partial loss in one (5.9%) patient. This shows the extent of breast tissue destruction and the challenge of aesthetic reconstruction of the affected breast by the reconstructive surgeon.The treatment of a number of the patients was impaired by financial constraint as many patients could not afford the cost for wound care and surgery for wound closure as well as for further procedures that may be needed to improve the aesthetic appearance of the affected breast. In our study, 11 (64.7%) patients declined surgery for wound coverage due to financial constraint and opted for outpatient wound care. Most of these patients were lost to follow-up in the clinic. The poor follow-up in the clinic also made it difficult to assess the long-term outcome of patients who had surgical procedures for wound coverage and resurfacing.


  Conclusion Top


Complicated lactational breast abscess, characterized by destruction of breast skin with or without breast tissue, is not uncommon among lactating women in our environment due to late presentation resulting from illiteracy, poverty, and cultural practice of seeking alternative medical practice. Its management is challenging as many patients lack resources for adequate treatment including surgical intervention at the initial presentation as well as revision procedures needed to improve breast appearance later. There is need for improved public awareness about the features of lactational mastitis and breast abscess and the need for early presentation at the hospital for appropriate intervention. Also health facilities and services should be made readily available to pregnant and nursing mothers at reduced cost and there should be wider coverage of the national health insurance scheme.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kang YD, Kim YM. Comparison of needle aspiration and vacuum-assisted biopsy in the ultrasound-guided drainage of lactational breast abscesses. Ultrasonography 2016;35:148-52.  Back to cited text no. 1
    
2.
Cantlie HB. Treatment of acute puerperal mastitis and breast abscess. Can Fam Phys 1988;34:2221-6.  Back to cited text no. 2
    
3.
Spencer JP. Management of mastitis in breastfeeding women. Am Fam Phys 2008;78:727-31.  Back to cited text no. 3
    
4.
Martin JG. Breast abscess in lactation. J Midwifery Women Health 2009;54:150-1.  Back to cited text no. 4
    
5.
Kataria K, Srivastava A, Dhar A. Management of lactational mastitis and breast abscesses: review of current knowledge and practice. Indian J Surg 2013;75:430-5.  Back to cited text no. 5
    
6.
Afridi SP, Alam SN, Ainuddin S. Aspiration of breast abscess through wide bore 14-gauge intravenous cannula. J Coll Phys Surg Pak 2014;24:719-21.  Back to cited text no. 6
    
7.
Trop I, Dugas A, David J, El Khoury M, Boileau JF, Larouche N et al. Breast abscesses: evidence-based algorithms for diagnosis, management, and follow-up. Radiographics 2011;31:1683-99.  Back to cited text no. 7
    
8.
Irusen H, Rohwer AC, Steyn DW, Young T. Treatments for breast abscesses in breastfeeding women. Cochrane Database Syst Rev 2015;(8):CD010490.  Back to cited text no. 8
    
9.
Elagili F, Abdullah N, Fong L, Pei T. Aspiration of breast abscess under ultrasound guidance: outcome obtained and factors affecting success. Asian J Surg 2007;30:40-4.  Back to cited text no. 9
    
10.
Abdul-Razzaq MS, Kadum HN. A clinical and bacteriological study of breast abscess in female patients. Med J Babylon 2014;11:359-64.  Back to cited text no. 10
    
11.
Karvande R, Ahire M, Bhole M, Rathod C. Comparison between aspiration and incision and drainage of breast abscess. Int Surg J 2016;3:1773-80.  Back to cited text no. 11
    


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