Oh wise ones,

I have a mom of twins who came to me complaining of severe breast pain.
Started in the left breast which is now "OK" and when I saw her, the nipples
hurt, but the worst part was the deep ductal pain which radiated from the
nipple to her back.  There was a tiny "bleb" on the end of the nipple; baby's
suck was lovely (both of them) as well as the latch.  No evidence of thrush at
that point, and symptoms were probably 5 for thrush, 3 for not thrush.  (I did
my pro/con list, including the fact that she LOVED heat on her nipples.  Most
moms with thrush like cold on their nipples).  Maybe a plugged duct.  So she
poked at the bleb and expressed some milk (no evidence of a plug).  Pain still
excruciating, so she pumped for 24 hours on that side which seemed to help.
Ibuprophen around the clock and an antifungal on the nipples just in case.  No
help.  Her sister in law (a doc) put her on diflucan at my recommendation
(cover all the basis).  She stopped the antifungal because the pain on the
nipples was much worse.  I went out of town, and when I got back, she had seen
another LC who had recommended gentian violet.  The stabbing pain in the ducts
was gone, but the nipples were still excruciatingly sore.  The gentian violet
did not help -- and, in fact, apparently burned the babies under the tongue as
they had blisters which popped & bled.  When I talked to her after getting
home, I recommended she go back on the antifungal cream for her nipples.
Since the babies had now been officially diagnosed with thrush and were also
on Nystatin, I recommended just keeping with that.  Meanwhile, her OB had put
her on Sporonox (you know, the toenail antifungal??).  I'd never heard of that
for anything BUT toenails, but then, what do I know??  Little uncomfortable
with that -- would rather have her back on the diflucan.  Peds put the babies
on diflucan, though now he's not sure the babies have thrush.  And, she called
me last night and the deep ductal pain is back.  Someone else suggested it was
ductal cramping and it would go away after awhile.  In my experience, ductal
cramping goes from the back of the breast to the nipple, not the nipple to the
back which is one way of a differential dignosis.

I'm stumped.  What do you all think of Sporonox for ductal yeast?  Shouldn't
the gentian violet have done SOMETHING if it was candidiasis?  (Apparently it
was recommended she use 1% TID for three days).  Does going back on the
diflucan make sense at this point?  And her nipples do feel better, except the
bleb is back, corresponding with the deep ductal pain.  However, she can
express milk from the duct that looks as though it is closed off, and doesn't
feel any lumps.  And picking at it the last time didn't do any good.

Let me know....oh wise ones.

Jan -- discouraged in Wheaton