The mastitis thread reminded me of a very interesting case which taught
me alot about mastitis several months ago.  I will have to go from
memory because my notes are in the hospital.
A primip  phoned me at 6wks pp with the following story.  She had left
our hospital with well established breastfeeding using a silicone
shield  due to the fact that  she had had a VE and she  could only nurse
lying down  in the early days and due to very large breasts, the baby
could only latch with the help of the shield and mom felt more
confident with it.  I advised her to try to discontinue  using it as
soon as she could, and she assured me that she   was in contact with an
LC and would do so with her help.
Now at 6 wks, she had her third case of mastitis.  First case occurred
10 days pp and was treated with homeopathic meds by her LC and partially
resolved.  Next flare-up occurred  within ten days and LC was away so
she went to her gynie who    told her that the reason that she is
experiencing frequent breast  infections is due to the fact that she is
American and because Americans bathe so frequently, they   have more
infections as opposed to another ethnic  group who don't.  Still waiting
for him to give me the reference on that one!!!!

He gave her a course of antibiotics which he changed halfway through
treatment ( memory fails me here, I think he started with amoxycillin
and changed to Orbenil.) The infection never really resolved,  and a
subsequent flare-up at 6 weeks resulted in her contacting me.
This as the other cases was in the same location, upper  right quadrant
of left breast.  What was strange this time was that she was afebrile
and experiencing no pain in the affected area.  This alarmed me and I
asked her to come   straight to our ER but to stop by and see me on the
way.
Her entire upper left  breast was angry purple.  Palpation revealed a
defined lump which was painless and did not change while the baby nursed
a vigorous feed on this side.  I felt no change in the lump with slight
pressure during the feed. The  whole area was painless.  A nurse was in
with me during the examination and we concurred that what probably had
happened was that the initial treatment with homeopathic substances ( no
memory of what it was) had cause healing but did not resolve the
infection.  Scar  tissue may have caused encapsulation and closed off
the blood supply to the area and hence no fever and no response to
antibiotics as well as no pain.

The possibility of this being initially caused by tumor remained in both
our minds and we sent her immediately to ER with instructions to perform
FNA prior to surgery. The surgeon on duty refused both FNA or ultrasound
and of course told the mom to stop breastfeeding.  AAAAARGH!  They
drained the abscess and the last time I spoke to the mom which was about
a month post-op she still felt a  nodule in the area.  By the way, every
time a gynie on our staff tells a mom to stop breastfeeding when she has
early signs of infection, I ask the doc if a  woman came to him with a
UTI would he tell her to stop urinating.  They all go away scratching
their heads and now they tell the moms to feed often on the affected
side or at least drain it.  DUH!!!!

Although she was under the care of another LC, I strongly urged her to
see a breast  specialist and perhaps someone  would ultrasound it or
perform a more in-depth examination.  She preferred to wait until the
baby was weaned.  I explained to her the possibilities, but she was
resisting.  I may just call her to say hi this week and find out what is
happening.  I just don't want to step on any of my colleagues toes.

Has anyone else had a similar experience with an abscess in an afebrile
patient who experiences no pain?  I think the encapsulation theory is
correct, but the cause is not clear.  Any ideas?

Esther Grunis, IBCLC
Lis Maternity Hospital
Tel Aviv, Israel
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