>
>There was no "typical" wedge shaped redness or lump, onset was sudden. Her
>whole R breast was red and swollen. She was slow to respond to abx (no change
in appearance of breast for >48 hrs). She is now back less than 10 days post
d/c (still on po abx) with same exact sx's but this time in L breast. Fever
is very high (39.9) and again slow to respond to abx. U/S showed "micro"
galactoceles throughout both breasts. Largest galactocele aspirated and was
sterile, results of blood cx's  and milk cultures not back yet. She is now
on vancomycin (in case of MRSA) and zosyn IV. As she has been so sick almost
since delivery, she is considering weaning (baby is thriving). She is sad
about this and also aware that she can not wean until infection is cleared
up. I have never seen this presentation nor has her MD. Any advice? What
about these diffuse galactoceles? Any help would be appreciated.

Dear Kimberly, although as you say the inflamed wedge or lump is the most
common or typical presentation in mastitis I have certainly seen the
symptoms you describe (diffuse erythema and oedema of the entire breast) in
a small proportion of women with mastitis. This presentation has always
occurred in the first week or two post partum, and as with your mum is
accompanied by particularly florid systemic symptoms, something which I
think probably strongly implicates a nosocomial infection. The bilateral
nature of the presentation also points to infection. As she has experienced
recurrence whilst taking ABs a culture and sensitivity of the milk is
important to ensure the appropriate type has been prescribed, although non
compliance with ABs given in the first instance should also be considered.
 My observations of these particular cases is that the duration of symptoms
is often very long with complete resolution of erythema taking up to 5 - 12
days. (One women had a palpable lump for 9 months post resolution of the
episode - we monitored this via ultrasound every few months and nothing
sinister eventuated. The US was very interesting, but another story).
Commonly I have also found that these women experience a seesawing of
pyrexia and their flu like symptoms. Just when you think they are responding
to the AB Rx (afebrile or low grade temp for 6-8 hours) the hyper pyrexia
returns with a vengeance. I have observed this to occur for more than 48 -72
hours before systemic symptoms begin to resolve (and this may be as a result
of the pro inflammatory milk cytokines leaking out into the systemic
circulation in addition to normal inflammatory response). Milk cultures are
mostly staph but I have seen Strep B so its probably not a bad idea to cover
for this until you have culture results. Occasionally in research
superantigens have been identified in mastitis isolates. These superantigens
can interfere with the normal immune response so symptoms can be more florid
and of longer duration. I have also seen in florid cases of this type, along
with the staph infection,  a heavy overgrowth of normal skin flora in a mid
stream sample. I'm sure this all contributes to the severity of the case.

These cases are really awful for a new Mum and it can be really hard to help
them see that once they get through this, breastfeeding can indeed become a
joy and a delight. If its of any encouragement to your Mum the mother I
mentioned with the ongoing lump post mastitis had almost the same
presentation with her first episode on Day 5 and her second on Day 12. She
was very sick for quite a while but went on to breastfeed well into her
baby's second year with no further episodes of mastitis.
With regard to the galctoceles (if indeed this is really what they are) - I
think this may be a bit of a red herring. There may be multiple small
blockages due to the changes that occur in milk with inflammation, that are
associated with distal dilatation of the duct (which might appear to be
galactocele like).

Regards
Cathy Fetherston CM MSc IBCLC
Western Australia

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