Hey everyone- I need  input from any greatly experienced gurus out there - 
I've been active in  both hosp and pr. practice x12yrs, and I've NEVER seen 
this- I am  stumped! 
(Barbara Clay/Kay Hoover's Brst Feeding Atlas has  ALMOST a dead ringer for 
what I'm seeing in plate#220 to 223- very similar case  study, but cultures are 
neg for MRSA.) 
I have mom's permission to post all this; I have  her permission to share her 
pics to elaborate on what is going on. Please email  me privately if you can 
help- 
I saw this mom @ 21d pp-: 
History: 
28 yr old   G1 P1 L1, great health -nml preg/ breast dev. No regular meds-  
protracted  nipples, mod length/girth.  
Mod lge breasts,  mod lge areolas - no abnormalities. 
Scheduled C/S- breech. Healthy Fe  infant, 6-0lbs.  
Infant to breast  approx 6hrs pp.  
Seen by  Hosp LC.  for Diff latching, pain and creasing of nipple.- lanolin.  
Infant w/nml output, swallowing. Short  frenulum  w/ frontal tongue tie. 
Parents chose no  frenotomy now, nurse w/ nipple shield. Nipples  cracked/ 
bleeding . Latch better, some creasing even with shield.  
Noticable crack  at base of R nipple. 
Mature milk  in  day 4-5 pp, Double electric pump rented at discharge to 
relieve mod  engorgement, worse on R.  Infant wght ok. 
week 1 post d/c.   Mo continues engorgement with limited relief via pumping, 
especially  on R side,. Treatment per hosp LC office: 
Cool compresses  (Mo was using heat until told cool - for early engorgement) 
Crack at base of  R nipple still present, not healing.APNO prescribed. 
On Day 8- develops  mastitis 
Dicloxacillin po  as per for mastitis.;ibuprofen for pain/ inflammation, cool 
compresses.R  breast engorgement unrelieved by pumping-crack is the  same. 
Fever 100-101. 
5 days  Dicloxacillin- no change in breast.  
Admitted hosp 5 days IV  Cephalexin.  Infant now fussy on R - doing well on  
L,-  
Minimal change of breast in hosp, supply from R breast down  to 1/2 oz, - , 
Mo continues attempting to  relieve residual fullness R breast via pumping, but 
reports condition only sl.  improved during hosp stay. Crack unchanged- 
Afebrile. 
Mo d/charge on  Keflex.  
R breast  continues same appearance next week - Infant  increased diff. 
nursing R-cabbage/cool compresses, pumping  R after nursing  d/t unrelieved 
engorgement.1/2 -1oz. . Weight 6-8, good gain.@ 18D  pp.-1 oz EBM occ. as top-up  
3 wks pp-Frenulotomy performed- no  complications. R Brst Ultrasound a few 
days ago - neg for  abscess.  
First  call from Mo to me-,  with emergent issue of  increased swelling, 
redness of R breast, burning pain in nipples w/pumping or  nursing;  unable to get 
any milk from R breast at  all.  
Mo instructed  via phone:  massage/soak breast in sink filled w/ warm h2o 
prior to pumping  and use RPS (rev press softening) until seen in AM by LC.( this 
was successful  in getting milk flowing-1oz) Mo choice no ibuprofen and  
monitor temp for next 12 hrs. 
Next AM  -Home visit LC :  
Mo low-grade fever, 99.6. 
L  breast: very sl reddened, full. No nipple trauma, mo reports nipple  
redder than normal. 
R  breast has marked redness involving total breast, hot , swollen,  with 
obvious peau d’orange appearance lateral breast extending into areolar area  
which is swollen and has irregular areas of density upon palpation. Body of  
breast  has irregular areas of  firmness and congestion, markedly so on lower and 
underside aspects of breast.  ( like BF Atlas figs. 220,207) 
R Areolar  expression obtains sm amount milk from only a few   pores.Crack 
@lateral base R nipple, approx 1cm w/ yellowish wet margins. Mo  reports no 
change in crack past few days.           
We improved  latch on L side w/shield resulting in vigorous swallowing and  
noticeable decrease of fullness. Burning nipple pain present throughout  
nursing.  
With infant on  L, simultaneous pumping on R produced MER w/in few minutes 
and minimal  softening of breast, 1 oz ebm obtained - nml in appearance. 
Attempt nurse R  side, no milk in shield although infant nurses steadily,  
Treatment next  24hrs: 
-Standard  treatment for mastitis on R,(Heat, massage before 
nursing/pumping,cabbage 2x day for swelling) 
-To help MER on  R : pump R while nursing L to get MER, then attempt nurse R 
side,  checking for swallowing and release of milk. (Pump  L after only if 
residual fullness). 
-If infant won't  nurse R side, cont. pumping R 15 mins with massage to 
soften  breast. 
-Continue APNO  as ordered 
- Suspect Candidiasis on  both nipples, (unrelieved 
burning/redness/antibiotic history) No thrush  noted in infant’s mouth. 
Recommend mo discuss poss. of  Candidiasis with MD-? Diflucan  for mo, and G 
Violet for infant. Gave mo  info re: OTC Gentian  per J Newman to share w/MD. 
My Impression so far:Unresolved mastitis from bacterial invasion through 
nipple base crack coupled  with stasis and engorgement. Antibiotic therapy  ineffe
ctive as evidenced by no improvement in breast condition. 
Note:  mo  reports that area of breast examined by ultrasound probe appeared 
not to include  sub-areolar regions, limited to body of breast and areolar 
ridge only. Mo’s  areolas approx 3.5-4 inches in diameter.  
? Abscess not  seen on ultrasound. 
Next  day: 
R  breast-Mo gets approx 1 oz EBM q fdng. Breast sl softening,  redness 
unchanged, congestion still obvious. Mo began Diflucan and G  Violet treatment per 
MD, with much decrease in burning sensations. 
L  breast-Infant nursing well  on L w/shield q 3 hrs. 
Day 24 Next  day (phone) 
R  Breast -while pumping,, a sudden amount of “egg yolk colored,  thick, 
sticky, pus-like material came from the crack at base of nipple- approx ½  oz”. 
This was followed by MER , producing 1 oz of milk from nipple which now has  
lumps in it. The yolk colored discharge from the crack gradually slowed, and had  
stopped by end of pumping. 
Mo has continued  low grade temp 99. 
-Continue plan q  3 hrs nurse L side w shield- pump on R. 
R breast  continues producing approx 1-1.5 EBM per pumping with 
minimalsoftening of  breast.  
-Heat to R  breast. 
-Freeze EBM,  don’t give to baby until organism identified. 
--Monitor temp 
-Notify MD re:  discharge and ? culture 
-Home visit in  AM   
Home visit (New year's Eve  Day) 
R  breast- redness and peau d’orange appearance unchanged.  Lateral and 
underside areas of congestion unchanged,  mo experiences sl  softening of other 
areas after pumping. R nipple tip now has developed  multiple yellowish fluid 
filled blisters over the nipple tip. These cause pain  during pumping.Mo had used 
a sterile needle to open  the largest blister on nipple tip which eased some 
of the pain when  pumping-  fluid was serous (clear) and yellow in color. 
Mo reports the  crack produced lessening amounts of yellow discharge at 
beginning of each  pumping as day went on; ceased by now. MER happens  after 
discharge, producing 1-1.5 oz normal-color milk with some  clumps in it. EBM is 
being frozen and not fed to infant. 
Mo continues  w/low-grade fever. 
My new Impression: 
? MRSA organism  may be causative, requiring immediate and aggressive 
antibiotic treatment  (Vancomycin?). 
? Abscess  suppurated through nipple base crack. 
I Contacted covering midwife for OB service and relayed my suspicions re: 
MRSA. 
Mo admitted to  hosp for workup and treatment - 
R nipple  base crack and milk sample cultured, Pending results, mo on 
Oxacillin IV  therapy.  
Next Day: 
Mo reports that  her own OB arrived at hosp, examined  breast,,stated it was 
unchanged from 2 weeks ago. Mo shared LC’s notes and  observations with OB who 
agreed there was a strong possibility of MRSA  infection. Patient started on 
Vancomycin stat. OB expects  improvement  within 48hrs of therapy.Infant 
started on formula at home,parent choice, infant  very fussy and agitated in hosp. 
NextDay;Culture of milk neg. IV  Vanc stopped, mo d/c home. Assumption by MD 
is that engorgement will not reslove  while mo continues to pump q 3-4 hrs, 
and engorgemant is the major  issue.Told by MD to stretch out time between 
pumping to decrease milk  supply, and to expect increase discomfort from breasts 
and low grade fever  during next few days. Now L breast is sl reddened and 
swollen d/t infrequent  nursing in hosp.  It was suggested to mo that she wean and 
formula feed.  
Then,Just  before discharge,mom pumps, and a sudden amount of “  thick, 
sticky, pus-like material with strings of yolk colored mixed in it" came  from 4 
nipple pores - approx ½ -oz volume. None came from the crack. This was  followed 
by an MER from nipple tip, producing 1.5 oz of milk which now has lumps  in 
it.  
The hosp LC happened to be there and saw the  discharge- obtained a sample 
for culturing. 
Mo leaves hosp for home. 
Next 24 hrs- Mo has no change in R  breast redness, swelling since home 
24hrs- spacing pumping out to q 5-6hrs.  Freezing milk. 
Now I am considering calling the discharging MD and  making sure they have 
ruled out inflammatory breast ca- 
Anybody else have any ideas what this could  be 

Lucia  Jenkins RN,IBCLC
Wakefield, Ma  01880
781-246-2059
cell781-507-1980
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