brand logo

JEANNE P. SPENCER, MD

Am Fam Physician. 2008;78(6):727-731

Patient information : See related handout on mastitis , written by the author of this article.

Author disclosure: Nothing to disclose.

Mastitis occurs in approximately 10 percent of U.S. mothers who are breastfeeding, and it can lead to the cessation of breastfeeding. The risk of mastitis can be reduced by frequent, complete emptying of the breast and by optimizing breastfeeding technique. Sore nipples can precipitate mastitis. The differential diagnosis of sore nipples includes mechanical irritation from a poor latch or infant mouth anomalies, such as cleft palate or bacterial or yeast infection. The diagnosis of mastitis is usually clinical, with patients presenting with focal tenderness in one breast accompanied by fever and malaise. Treatment includes changing breastfeeding technique, often with the assistance of a lactation consultant. When antibiotics are needed, those effective against Staphylococcus aureus (e.g., dicloxacillin, cephalexin) are preferred. As methicillin-resistant S. aureus becomes more common, it is likely to be a more common cause of mastitis, and antibiotics that are effective against this organism may become preferred. Continued breastfeeding should be encouraged in the presence of mastitis and generally does not pose a risk to the infant. Breast abscess is the most common complication of mastitis. It can be prevented by early treatment of mastitis and continued breastfeeding. Once an abscess occurs, surgical drainage or needle aspiration is needed. Breastfeeding can usually continue in the presence of a treated abscess.

Mastitis is defined as inflammation of the breast. Although it can occur spontaneously or during lactation, this discussion is limited to mastitis in breastfeeding women, with mastitis defined clinically as localized, painful inflammation of the breast occurring in conjunction with flu-like symptoms (e.g., fever, malaise).

Mastitis is especially problematic because it may lead to the discontinuation of breast-feeding, which provides optimal infant nutrition. The Healthy People 2010 goals for breastfeeding are that 75 percent of mothers initiate breastfeeding, with 50 percent and 25 percent continuing to six and 12 months, respectively. 1 As of 2005, most states were not meeting these goals ( Figure 1 ) . 2 To extend breastfeeding duration, family physicians must become more adept at helping mothers overcome breastfeeding difficulties such as mastitis.

The incidence of mastitis varies widely across populations, likely because of variations in breastfeeding methods and support. Studies have reported the incidence to be as high as 33 percent in lactating women. 3 One study of 946 lactating women, followed prospectively, found an incidence of 9.5 percent. 4 Although mastitis can occur anytime during lactation, it is most common during the second and third weeks postpartum, with 75 to 95 percent of cases occurring before the infant is three months of age. 3 It is equally common in the right and left breast. 5 Risk factors for mastitis are listed in Table 1 . 3 , 4 , 6 – 8

Prevention of Mastitis

Few trials have been published on methods to prevent mastitis. Most interventions are based on clinical experience and anecdotal reports. Because mastitis is thought to result partly from inadequate milk removal from the breast, optimizing breastfeeding technique is likely to be beneficial. However, one trial showed that a single 30-minute counseling session on breastfeeding technique does not have a statistically significant effect on the incidence of mastitis. 9 Therefore, ongoing support may be necessary to achieve better results. Lactation consultants can be invaluable in this effort. In addition, bedside hand disinfection by breastfeeding mothers in the postpartum unit has been shown to reduce the incidence of mastitis. 10

Risk Factors

Sore nipples may be an early indicator of a condition that may predispose patients to mastitis. In the early weeks of breastfeeding, sore nipples are most often caused by a poor latch by the feeding infant. The latch can best be assessed by someone experienced in lactation who observes a feeding. Wearing plastic-backed breast pads can lead to irritation of the nipple from trapped moisture. 11 For sore nipples that are overly dry, the application of expressed breast milk or purified lanolin can be beneficial. 11

Nipple fissures can cause pain and can serve as a portal of entry for bacteria that result in mastitis. One study randomized mothers with cracked nipples who tested positive for Staphylococcus aureus to breastfeeding education alone, application of topical mupirocin (Bactroban) 2% ointment or fusidic acid ointment (not available in the United States), or oral therapy with cloxacillin (no longer available in the United States) or erythromycin. 12 The mothers in the oral antibiotic group had significantly better resolution of cracked nipples.

Blocked milk ducts can also lead to mastitis. This condition presents as localized tenderness in the breast from inadequate milk removal from one duct. A firm, red, tender area is present on the affected breast, and a painful, white, 1-mm bleb may be present on the nipple. This bleb is thought to be an overgrowth of epithelium or an accumulation of particulate or fatty material. Removal of the bleb with a sterile needle or by rubbing with a cloth can be beneficial. 3 Other treatments include frequent breastfeeding and the use of warm compresses or showers. Massaging the affected area toward the nipple is often helpful. Constrictive clothing should be avoided.

Yeast infection can increase the risk of mastitis by causing nipple fissures or milk stasis. Yeast infection should be suspected when pain—often described as shooting from the nipple through the breast to the chest wall—is out of proportion to clinical findings. This condition is often associated with other yeast infections, such as oral thrush or diaper dermatitis. Culture of the milk or the infant's mouth is rarely useful. Treatment of both the mother and infant is essential. Topical agents that are often effective include nystatin (Mycostatin) for the infant or mother, or miconazole (Micatin) or ketoconazole (Nizoral, brand no longer available in the United States) for the mother. 11 Application of 1% gentian violet in water is an inexpensive and often effective (although messy) alternative. Before a feeding, the solution is applied with a cotton swab to the part of the infant's mouth that comes into contact with the nipple. After the feeding, any areas of the nipple that are not purple are painted with the solution. This procedure is repeated for three to four days. 13 Although it is not approved by the U.S. Food and Drug Administration for the treatment of mastitis, fluconazole (Diflucan) is often prescribed for the mother and infant with severe cases of mastitis. The dosage for the mother is 400 mg on the first day, followed by 200 mg daily for a minimum of 10 days. Single-dose treatment, such as that used for vaginal candidiasis, is ineffective. 11 The infant is not adequately treated by the fluconazole that passes into the breast milk and should be treated with 6 to 12 mg per kg on the first day, followed by 3 to 6 mg per kg per day for at least 10 days. 14

Infant mouth abnormalities (e.g., cleft lip or palate) may lead to nipple trauma and increase the risk of mastitis. Infants with a short frenulum ( Figure 2 ) may be unable to remove milk effectively from the breast, leading to nipple trauma. Frenotomy can reduce nipple trauma and is usually a simple, bloodless procedure that can be performed without anesthesia. 15 The incision is made through the translucent band of tissue beneath the tongue, avoiding any blood vessels or tissue that can contain nerves or muscle. 11

case study mastitis

The diagnosis of mastitis is generally made clinically. Patients typically present with localized, unilateral breast tenderness and erythema, accompanied by a fever of 101°F (38.5° C), malaise, fatigue, body aches, and headache. 5 , 11 Figure 3 shows an example of the clinical appearance of mastitis.

case study mastitis

Culture is rarely used to confirm bacterial infection of the milk because positive cultures can result from normal bacterial colonization, and negative cultures do not rule out mastitis. 3 , 7 , 16 Culture has been recommended when the infection is severe, unusual, or hospital acquired, or if it fails to respond to two days' treatment with appropriate antibiotics. 3 Culture can also be considered in localities with a high prevalence of bacterial resistance. To culture the milk, the mother should cleanse her nipples, hand express a small amount of milk, and discard it. She should then express a milk sample into a sterile container, taking care to avoid touching the nipple to the container. 17

Treatment of mastitis begins with improving breastfeeding technique. If the mother stops draining the breast during an episode of mastitis, she will have increased milk stasis and is more likely to develop an abscess. Consultation with an experienced lactation consultant is often invaluable. Mothers should drink plenty of fluids and get adequate rest. 3 , 17 Therapeutic ultrasound has not been proven helpful. Homeopathic remedies have not been well studied for safety or effectiveness. 18

Because the mother and infant are usually colonized with the same organisms at the time mastitis develops, breastfeeding can continue during an episode of mastitis without worry of the bacterial infection being transmitted to the infant. 3 In addition, milk from a breast with mastitis has been shown to contain increased levels of some anti-inflammatory components that may be protective for the infant. 19 Continuation of breastfeeding does not pose a risk to the infant; in fact, it allows for a greater chance of breastfeeding after resolution of the mastitis and allows for the most efficient removal of the breast milk from the affected area. However, some infants may dislike the taste of milk from the infected breast, possibly because of the increased sodium content. 20 In these cases, the milk can be pumped and discarded.

Vertical transmission of human immunodeficiency virus (HIV) from mother to infant is more likely in the presence of mastitis. 3 , 21 This is especially important in developing countries where mothers who are HIV-positive may be breastfeeding. 3 The World Health Organization recommends that women with HIV infection who are breastfeeding be educated on methods to avoid mastitis, and that those who develop mastitis avoid breastfeeding on the affected side until the condition resolves. 3

In addition to draining breast milk as thoroughly as possible, antibiotics are often necessary to treat mastitis. Few studies are available to guide the physician in determining when antibiotics are needed, or in selecting antibiotics. If a culture was obtained, results can guide therapy. Because the most common infecting organism is S. aureus , antibiotics that are effective against this organism should be selected empirically. Table 2 lists antibiotics that are commonly used to treat mastitis. 11 , 17 , 22 The duration of antibiotic therapy is also not well studied, but usual courses are 10 to 14 days. 17 A Cochrane review of antibiotic treatment for mastitis in lactating women is currently underway. 23

As outpatient infection with methicillin-resistant S. aureus (MRSA) becomes increasingly common, physicians need to be aware of the local prevalence and sensitivities of this organism. A recent case report describes MRSA contamination of expressed breast milk and implicates this in the death of a premature infant with sepsis. 24 Organisms other than S. aureus have rarely been implicated as the cause of mastitis. These include fungi such as Candida albicans , as well as group A beta-hemolytic Streptococcus , Streptococcus pneumoniae , Escherichia coli , and Mycobacterium tuberculosis . 7 , 11

Complications

One of the most common complications of mastitis is the cessation of breastfeeding. Mothers should be reminded of the many benefits of breastfeeding and encouraged to persevere. Another potential complication is the development of an abscess, which presents similarly to mastitis except that there is a firm area in the breast, often with fluctuance. An abscess can be confirmed by ultrasonography and should be treated with surgical drainage or needle aspiration, which may need to be repeated. Fluid from the abscess should be cultured, and antibiotics should be administered, as outlined in Table 2 . 11 , 17 , 22 Breastfeeding usually can continue, except if the mother is severely ill or the infant's mouth must occlude the open incision when feeding. 20

Because inflammatory breast cancer can resemble mastitis, this condition should be considered when the presentation is atypical or when the response to treatment is not as expected.

The International Lactation Consultant Association is an organization of board-certified lactation consultants. Its Web site ( http://www.ilca.org ) lists local lactation consultants worldwide. La Leche League International ( http://www.llli.org ) has many handouts to assist breastfeeding mothers with common problems (e.g., sore nipples).

Centers for Disease Control and Prevention. Healthy People 2010 objectives for the nation. http://www.cdc.gov/breastfeeding/policies/policy-hp2010.htm. Accessed October 23, 2007.

Centers for Disease Contol and Prevention. Breast-feeding practices—results from the National Immunization Survey. http://www.cdc.gov/breastfeeding/data/NIS_data/data_2004.htm and http://www.cdc.gov/breastfeeding/data/NIS_data/images/map_6mo_2005.gif. Accessed October 23, 2007.

Department of Child and Adolescent Health and Development. Mastitis: causes and management. Geneva, Switzerland: World Health Organization; 2000. http://whqlibdoc.who.int/hq/2000/WHO_FCH_CAH_00.13.pdf . Accessed June 15, 2008.

Foxman B, D'Arcy H, Gillespie B, Bobo JK, Schwartz K. Lactation mastitis: occurrence and medical management among 946 breastfeeding women in the United States. Am J Epidemiol. 2002;155(2):103-114.

Wambach KA. Lactation mastitis: a descriptive study of the experience. J Hum Lact. 2003;19(1):24-34.

Fetherston C. Risk factors for lactation mastitis. J Hum Lact. 1998;14(2):101-109.

Walker M. Mastitis and the Lactating Woman . Schaumburg, Ill: La Leche League International; 2004. Unit 2 Lactation Consultant Series Two. No. 1603–19.

Martin J. Is nipple piercing compatible with breastfeeding?. J Hum Lact. 2004;20(3):319-321.

de Oliveira LD, Giugliani ER, do Espírito Santo LC, et al. Effect of intervention to improve breastfeeding technique on the frequency of exclusive breastfeeding and lactation-related problems. J Hum Lact. 2006;22(3):315-321.

Peters F, Flick-Filliés D. Hand disinfection to prevent puerperal mastitis. Lancet. 1991;338(8770):831.

Lawrence RA, Lawrence RM. Management of the mother-infant nursing couple. In: Breastfeeding: A Guide for the Medical Profession . 6th ed. St. Louis, Mo.: Mosby; 2005:255–316.

Livingstone V, Stringer LJ. The treatment of Staphyloccocus aureus infected sore nipples: a randomized comparative study [published correction appears in J Hum Lact . 2000;16(2):179]. J Hum Lact. 1999;15(3):241-246.

Newman J. Using gentian violet. http://www.bflrc.com/newman/breastfeeding/gentviol.htm. Accessed October 23, 2007.

Chetwynd EM, Ives TJ, Payne PM, Edens-Bartholomew N. Fluconazole for postpartum candidal mastitis and infant thrush. J Hum Lact. 2002;18(2):168-171.

Ballard JL, Auer CE, Khoury JC. Ankyloglossia: assessment, incidence, and effect of frenuloplasty on the breastfeeding dyad. Pediatrics. 2002;110(5):e63.

Osterman KL, Rahm VA. Lactation mastitis: bacterial cultivation of breast milk, symptoms, treatment, and outcome. J Hum Lact. 2000;16(4):297-302.

Academy of Breastfeeding Medicine. Protocol #4: mastitis. http://www.bfmed.org/ace-files/protocol/ProtocolMastitis4rev.pdf. Accessed October 23, 2007.

Barbosa-Cesnik C, Schwartz K, Foxman B. JAMA. Barbosa-CesnikCSchwartzKFoxmanBLactation mastitis.JAMA2003;289(13):1609–1612.

Buescher ES, Hair PS. Human milk anti-inflammatory component contents during acute mastitis. Cell Immunol. 2001;210(2):87-95.

Prachniak GK. Common breastfeeding problems. Obstet Gynecol Clin North Am. 2002;29(1):77-88.

Michie C, Lockie F, Lynn W. The challenge of mastitis. Arch Dis Child. 2003;88(9):818-821.

National Library of Medicine. Toxicology Data Network (TOXNET). Trimethoprim-sulfamethoxazole. Drug and Lactation Database (LACTMED). http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT . Accessed June 15, 2008.

Ng C, Jahanfar S, Teng CL. Antibiotics for mastitis in breastfeeding women [Protocol]. Cochrane Database Syst Rev. 2005;3:CD005458.

Gastelum DT, Dassey D, Mascola L, Yasuda LM. Transmission of community-associated methicillin-resistant Staphylococcus aureus from breast milk in the neonatal intensive care unit. Pediatr Infect Dis J. 2005;24(12):1122-1124.

Continue Reading

More in afp, more in pubmed.

Copyright © 2008 by the American Academy of Family Physicians.

This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP.  See permissions  for copyright questions and/or permission requests.

Copyright © 2024 American Academy of Family Physicians. All Rights Reserved.

  • Research article
  • Open access
  • Published: 11 October 2006

A case-control study of mastitis: nasal carriage of Staphylococcus aureus

  • Lisa H Amir 1 ,
  • Suzanne M Garland 2 &
  • Judith Lumley 1  

BMC Family Practice volume  7 , Article number:  57 ( 2006 ) Cite this article

10k Accesses

27 Citations

3 Altmetric

Metrics details

Mastitis is a common problem for breastfeeding women. Researchers have called for an investigation into the possible role of maternal nasal carriage of S. aureus in the causation of mastitis in breastfeeding women.

The aim of the study was to investigate the role of maternal S. aureus nasal carriage in mastitis. Other factors such as infant nasal S. aureus carriage, nipple damage, maternal fatigue and oversupply of milk were also investigated. A case-control design was used. Women with mastitis (cases, n = 100) were recruited from two maternity hospitals in Melbourne, Australia (emergency departments, breastfeeding clinics and postnatal wards). Breastfeeding women without mastitis (controls, n = 99) were recruited from maternal and child health (community) centres and the rooms of a private obstetrician. Women completed a questionnaire and nasal specimens were collected from mother and baby and placed in charcoal transport medium. Women also collected a small sample of milk in a sterile jar.

There was no difference between nasal carriage of S. aureus in breastfeeding women with mastitis (42/98, 43%) and control women (45/98, 46%). However, significantly more infants of mothers with mastitis were nasal carriers of S. aureus (72/88, 82%) than controls (52/93, 56%). The association was strong (adjusted OR 3.23, 95%CI 1.30, 8.27) after adjustment for the following confounding factors: income, private health insurance, difficulty with breastfeeding, nipple damage and tight bra. There was also a strong association between nipple damage and mastitis (adjusted OR 9.34, 95%CI 2.99, 29.20).

We found no association between maternal nasal carriage of S. aureus and mastitis, but nasal carriage in the infant was associated with breast infections. As in other studies of mastitis, we found a strong association between nipple damage and mastitis. Prevention of nipple damage is likely to reduce the incidence of infectious mastitis. Mothers need good advice about optimal attachment of the baby to the breast and access to skilled help in the early postpartum days and weeks.

Peer Review reports

Mastitis is a common problem for breastfeeding women [ 1 – 3 ] yet it is a poorly researched topic [ 4 ]. Mastitis may be a noninfective inflammation, resolving with heat and increased breast drainage [ 5 , 6 ], or an infective process which may lead to a breast abscess [ 7 ].

The most commonly isolated organism in lactating women with mastitis is Staphylococcus aureus ( S. aureus ): present in 32% to 44% of breast milk samples [ 8 – 11 ]. S. aureus is a commensal which may colonise the nostrils, axillae, vagina and pharynx of 30 to 50% of adults; as well as damaged skin, such as traumatised nipples of lactating women [ 12 , 13 ]. When S. aureus are present in the nostrils, they may act as a reservoir of S. aureus for clinical infections in the host or may facilitate spread to other people [ 14 ]. A review has concluded that four studies conducted in the 1990s found that S. aureus nasal carriers had a relative risk of 7.1 (95%CI 4.6, 11.0) of surgical-site infections, due to wound colonisation by the patient's endogenous flora [ 15 ].

Researchers have called for an investigation into the possible role of maternal nasal carriage of S. aureus in the causation of mastitis [ 16 ]. In clinical practice, there is anecdotal evidence that maternal or infant nasal carriage may be linked to recurrent mastitis in lactating women [ 17 ]. Our literature review did not identify any studies investigating the role of maternal or infant nasal carriage of S. aureus in mastitis. Medline searches (via PubMed) were conducted using keywords "staph* AND (lactation OR breastfeeding OR postpartum OR mastitis)" limited to human studies. A recent update (31 May 2006) has identified one case study of a mother of premature quadruplets who had symptoms of mastitis; methicillin-resistant S. aureus (MRSA) was isolated in expressed breast milk and nasal cultures from mother and infants [ 18 ].

We conducted a case-control study to examine the possible role of maternal nasal carriage of S. aureus in the development of mastitis. The role of S. aureus nasal carriage in the infant and other factors reputed to predispose women to mastitis, such as nipple damage, maternal fatigue and oversupply of milk, were also assessed.

Cases were women with mastitis attending the Emergency Department or the Breastfeeding Clinic at the Royal Women's Hospital or Mercy Hospital for Women in Melbourne, Australia. Mastitis was defined as at least two breast signs or symptoms (pain, redness or lump) and one systemic symptom (fever or 'flu-like symptoms) present for at least twelve hours.

Women in the control group were lactating women (with babies aged six weeks or less) attending Maternal and Child Health (MCH) centres in metropolitan Melbourne (community clinics attended by new mothers). Also, women attending a private obstetrician for their six-week postnatal visit were invited to join the study.

After women gave written consent, they completed a questionnaire about nipple damage, oversupply of milk and other factors identified as possible predisposing factors for mastitis. Maternal fatigue was assessed using the four Vitality questions from the SF-36 [ 19 ]. (The SF-36 Health Survey is one of the most widely used health-related quality of life questionnaires, measuring eight health concepts, including Physical functioning, Social functioning and Vitality) [ 19 ]. At the end of the questionnaire for women with mastitis, participants were asked to describe "how you have been feeling and how mastitis has affected you"; the results of these open-text comments have been published separately [ 20 ].

Nasal specimens were collected from mother and baby. Saline-moistened swabs were rotated around the inside of the nasal vestibule, then placed in Amies charcoal transport medium. Women used a sterile water wipe to cleanse her nipple then expressed a small sample of milk in a sterile jar. Specimens were labelled and delivered to the microbiology laboratory at the Royal Children's Hospital, where the swabs were inoculated on Mannitol Salt Agar plates, a medium selective for staphylococci. An aliquot of expressed breast milk was also placed on a Mannitol Salt Agar plate. S. aureus was confirmed with DNase test (thermostable nuclease) and antibiotic susceptibility was conducted using standard microbiological methods.

Using Epi-Info 6.0 for an unmatched case-control study with 95% confidence and 80% power, if 20% of controls were nasal carriers and 40% of cases, we would need 91 women in each group. We planned to recruit 100 cases (women with mastitis) and 100 controls (women in the community). The data were analysed by Stata 8.0 computer program. The comparability of cases and control groups were described. Odds Ratios were calculated to compare exposures in each group, and Mantel-Haenszel Weighted Odds Ratios where appropriate. Logistic regression was used to determine factors predictive of mastitis.

Four infants over 6 weeks age were inadvertently recruited for the control group (two at 7 weeks, one 9 and one 11 weeks). A sensitivity analysis was conducted by repeating the analysis without these infants and the results were found to be almost identical: therefore the records of these four mothers and babies were retained in the sample.

Ethics approval:

La Trobe University Human Ethics Committee (21/8/02 Project 02-61)

Research and Ethics Committees, Royal Women's Hospital (23/7/02, Project 02/22)

Research Ethics Committee, Mercy Hospital for Women (17/7/02, Project R02/32)

Department of Human Services, Victoria (5/6/02, Project 36/02).

One hundred women with mastitis (cases) and ninety-nine breastfeeding women (controls) were recruited between August 2002 and April 2004. Recruiting was stopped as the database incorrectly indicated that 100 controls had been recruited.

Fifty-four women with mastitis were recruited at the Mercy Hospital for Women and 46 women at the Royal Women's Hospital; from the breastfeeding clinics (n = 38), readmitted with mastitis in the wards (n = 32) and through the emergency departments (n = 25; 5 missing data). Most of the women for the control group were recruited through MCH centres (n = 70), whilst 29 women were from the private obstetrician.

Characteristics of study population

The background characteristics are displayed in Table 1 . Women with mastitis were older than women in the control group (34 years and 32 years, p < 0.05), while the median age of the babies was 16 days for cases and 36 days for controls. Family income was lower in the women with mastitis and they were less likely to have private health insurance.

Table 2 shows the health of women and their infants. After a question to determine if women had experienced mastitis in the past, women were asked "Have you ever had any other staph bacterial infections? For example: boils, abscesses, sores inside your nose?" Women with mastitis were more likely to have self-reported a past history of staphylococcal infection(s), 23% compared to 12%.

The sum of the scores from the four Vitality questions in the SF36 ranged from 4 (low) to 17 (high), with a mean of 10.7 (n = 195). Women were dichotomised into two groups scoring above or below the mean, and the groups compared. Sixty-one percent of women with mastitis scored below the mean vitality score, compared to 26% of controls. However, it is possible that some women were reporting lethargy associated with the onset of mastitis.

The breastfeeding characteristics of the sample can be seen in Table 3 . Cases were more likely to have had nipple pain (71%) compared to controls (35%), and more likely to be using purified lanolin on their nipples (64%) than controls (35%). Thirteen cases used topical antifungal cream/ointment/gel, while nine controls used topical antifungal treatment (not significant). More cases used nipple shields (16%) than controls (2%). Cases were also more likely to have experienced breast engorgement in the previous week (51%) than controls (19%), were more likely to say that they had missed a feed (54%) than the controls (36%) and that they had too much milk: 29% compared to 17%. Women were asked about pressure on their breasts in the previous week. More cases reported pressure from a tight bra (37%) than controls (20%).

Women with mastitis were more likely to report that their infant was having difficulty with breastfeeding, 57%, than the control group, 14%. Ten women with mastitis were currently feeding their infant expressed breast milk only, while none of the women in the control group was expressing only.

Microbiological results

There was no difference between nasal carriage of S. aureus in women with mastitis (43%) and women in the control group (46%) (Table 4 ). The overall proportion of women with a positive nasal culture for S. aureus was 44.4% (Binomial Exact 95% CI 37.3, 51.6). (MRSA was not isolated in any specimens in this study).

As expected, the expressed breast milk of women with mastitis was more likely to be positive for S. aureus (45/99, 46%), than the milk of controls (15/83, 18%). Most of the S. aureus isolated from the milk of the controls was reported as 'sparse" (11/15, 73%). Only one specimen in the control group was reported as "profuse" (1/15, 7%) compared to 14/45 (31%) in the mastitis group.

Significantly more infants of mothers with mastitis were nasal carriers of S. aureus (72/88, 82%) than infants in the control group (52/93, 56%, OR 3.55, 95%CI 1.80, 7.00). A high proportion of S. aureus in both groups was reported as "profuse", 66% of cases and 50% of controls, 59% in total. Overall, 68.5% of infants were nasal carriers of S. aureus (Binomial Exact 95% CI 61.2, 75.2).

The youngest infants were most likely to be nasal carriers (91% of infants in the first two weeks in the mastitis group), compared to 78% of infants aged 5–6 weeks. A stratified analysis of S. aureus nasal carriage in the infants was conducted to examine the results in babies at different ages. The Mantel-Haenszel weighted Odds Ratio was 3.49 (95%CI 1.38, 8.83) for infants of mothers with mastitis to be nasal carriers compared to infants in the control group (Table 5 ).

A statistically significant association was found between women with a cracked nipple and nasal carriage of S. aureus in their infants. Eighty-four percent (38/45) of women with a cracked nipple had a baby with nasal S. aureus , compared to 63% (85/135) of women without a cracked nipple, OR 3.19 (95%CI 1.33, 7.69). However, there was no association between nasal carriage in the mother and a cracked nipple: carriage in women with a cracked nipple was 39% (19/49) compared to 46% (67/146) of women without a cracked nipple.

Multivariate analysis

A logistic regression model was developed to look at factors predictive of mastitis. The independent variables of interest were tested individually against the dependent variable and were entered in the model if the p-value of the Wald statistic was ≤ 0.25 [[ 21 ], p95]. Where there were small numbers of missing values, records were deleted (seven records). Fifteen women had missing values for income, and sixteen babies did not have a result for nasal swab. These records were retained with the missing values coded accordingly. This left 192 records for analysis.

The initial model included the following variables: mother's age, income (2 levels), private health insurance, past history of staphylococcal infection, baby having difficulty with breastfeeding, nipple cracked, engorged breast/s, missed feed/s, tight bra, too much milk, using lanolin on nipple/s, baby positive for nasal S. aureus , mother anaemic, baby prefers one breast. Variables were eliminated one at a time using logistic regression. Only those with a p-value of the Wald statistic ≤ 0.05 were retained in the model. The process was repeated until only significant variables remained. Then all independent variables eliminated in the original univariate analysis were added back into the model one at a time to check that none was now significant given the reduced model. The lroc test identified that the area under ROC curve was 0.8778, that is a high sensitivity, and the lstat test showed 80.73% correctly classified. The final model (Model 1) is presented in Table 6 .

The adjusted Odds Ratio for infants of mothers with mastitis to be nasal carriers was 3.23 (95%CI 1.30, 8.27) after adjusting for possible confounding factors (Model 1). In order to explore the effects of breastfeeding factors and baby nasal carriage without including demographic factors, a second model was developed (Model 2). Without including the demographic variables (income and private health insurance), the second model is very similar to Model 1. In a third model (not shown), the demographic variables were included while limiting the analysis to private patients (n = 126), and the results were also similar. A fourth model (not shown, n = 184), excluding all babies over 7 weeks also found that infant nasal carriage was significant (adjusted OR 4.08, 95%CI 1.44, 11.67).

Summary of main findings and comparison with existing literature

The study showed that there was no difference in the proportion of women with mastitis and without mastitis who were nasal carriers (43% and 46% respectively). The overall proportion of women with a positive nasal culture for S. aureus was 44.4% (95% CI 37.3, 51.6). This is consistent with the mean of 37.2% in general populations calculated by Kluytmans and colleagues from eighteen studies in 13,873 people [ 15 ], but seems higher than other studies published in 2004: 29% [ 22 ], 24% [ 23 ] and 33% [ 24 ].

We found that a very high proportion of infants of mothers with mastitis were nasal carriers: 82% and this was statistically significantly higher than infants of other women (56%). Infant nasal carriage remained significant after adjusting for other variables. Younger infants were most likely to be nasal carriers than older infants in this study. In a similar manner, Peacock and colleagues found that 40–50% of infants were colonised with S. aureus in the first eight weeks, falling to 21% by six months [ 25 ].

An association was not found between parity or a history of mastitis and being a case in this study, in contrast to previous studies [ 2 , 16 ]. This may be related to the high proportion of primiparous women in both groups of our study. Also, women with a history of mastitis may have been more likely to volunteer to be a control than other women.

The presence of a cracked nipple was associated with a high odds for mastitis, 9.34 (95%CI 2.99, 29.20), after adjusting for other factors. Foxman and colleagues also found an association with "nipple cracks or sores" with an OR of 3.4 (95%CI 2.04, 5.51) on logistic regression [ 16 ]. Prevention of nipple damage is likely to reduce the incidence of infectious mastitis. New mothers need good advice about optimal attachment of the baby to the breast and access to skilled help in the early postpartum days and weeks.

This study found that using lanolin on nipples was significantly associated with mastitis on univariate analysis; however this was no longer significant on multivariate analysis. We expect that the association between creams on nipples and mastitis [ 26 ] is more likely to be related to the fact that nipple creams tend to be used when the nipples are damaged, and it is the nipple damage that probably is the route by which infection enters the breast rather than the creams themselves.

S. aureus was isolated in the milk of 46% of women with mastitis, a similar proportion to studies over the last thirty years [ 11 ]. S. aureus was also isolated in the milk of 17% of women without mastitis; mostly reported as "sparse" (11/15), probably reflecting contamination of the milk by bacteria on the skin of the nipple or the hands. In other studies between 0 and 20% of milk specimens from healthy women are positive for S. aureus [ 27 , 28 ].

Although it is not possible to conclude whether transmission occurred from the infant to the mother's breast or visa versa, it is likely that S. aureus was transmitted from the infant to the mother. In 1957, Wysham and colleagues demonstrated that 7 of 9 infants with positive throat cultures for S. aureus transmitted the organism to their bottle of formula milk [ 29 ]. Babies are born sterile and acquire their colonisation from their mother or the hands of health workers. Mothers and infants have been shown to be likely to carry the same strain of S. aureus [ 25 , 30 ]. Staphylococci may be transferred from the mother's nose to the infant's and then back to the mother's nipple, particularly if the nipple has been traumatised.

Strengths and limitations of this study

The diagnosis of mastitis relied on clinical signs and symptoms as there are no definitive tests for mastitis in women. The women in this study experienced either fever or systemic symptoms for at least 12 hours. Future studies could assess the usefulness of testing milk for the presence of leukocytes [ 31 ]. Molecular microbiology (eg pulsed field gel electrophoresis, PFGE) testing of isolates could have confirmed the clonality of S. aureus strains present in mothers with mastitis and in their infants. However, funding for this study was not sufficient to conduct PFGE.

It was originally planned to recruit women for the control group through MCH centres in the community (n = 25). However, we relied on women being referred to the study and recruitment was slow, so we started recruiting women attending a private obstetrician for their six-week postnatal check up. It would have been inappropriate to recruit women attending the hospital (Emergency Department or Breastfeeding clinic) as we were seeking women without problems for the control group. Therefore the controls were more likely to be private patients than cases, which resulted in more women from the higher income group as controls than cases. In order to assess if this had an effect on the study results, a logistic regression model was developed using only women with private insurance and similar results were obtained as when the model included all women.

A limitation of the case-control design is that any associations identified cannot be concluded to be causal. For example, private health insurance appears to be protective against mastitis (OR 0.27, 95%CI 0.14, 0.51), but this association is due to the selection bias that occurred during recruitment. The association between nasal S. aureus carriage in infants and mastitis in their mothers (adjusted OR 3.19, 1.23, 8.29) appears to be robust as it was significant in each logistic regression model. However, it does not tell us if this association proves a link between nasal carriage and mastitis nor in which direction the transmission is occurring.

Implications for clinical practice and future research

Mastitis is an acute painful illness, not limited to the breast, and often associated with a negative emotional response [ 20 ]. In order to prevent mastitis, clinicians could advice new mothers about the factors commonly associated with this problem, such as milk stasis caused by missed feeds, expressing and breast restriction [ 32 ]. Breastfeeding women can be alert for the early symptoms of mastitis when they have been extra busy, for example when travelling or when they have visitors staying. If women have anticipatory guidance they can overcome milk stasis in these situations by increasing breastfeeds or expressing more frequently.

Future studies need to aim to collect clinical specimens prospectively in order to determine the transmission dynamics between mother and infant. Molecular microbiology (e.g. PFGE) can be used to confirm that the same strain of S. aureus is present in mother and child, and the direction of transmission of organisms between mother and child.

It is not standard practice for mothers to wash hands before breastfeeding (less than 50% of women in both groups "always" washed hands). Future studies could focus on hand washing as S. aureus may be carried transiently on the hands [ 33 ] and can then be transferred to the breast. Hospitals should be aware of the possibility of transmission of potential pathogens on breast pumps; disinfection is particularly important after equipment is used by women with breast infections.

Another topic for future research is recurrent mastitis. Would it be possible to reduce recurrences of mastitis by reducing nasal carriage of S. aureus in mothers and infants where mothers have already experienced an episode of mastitis?

In conclusion, we found no association between maternal nasal carriage of S. aureus and mastitis, but nasal carriage in the infant was associated with breast infections. As in other studies of mastitis, we found a strong association between nipple damage and mastitis.

Kinlay JR, O'Connell DL, Kinlay S: Incidence of mastitis in breastfeeding women during the six months after delivery: a prospective cohort study. Med J Aust. 1998, 169: 310-312.

CAS   PubMed   Google Scholar  

Vogel A, Hutchison BL, Mitchell EA: Mastitis in the first year postpartum. Birth. 1999, 26: 218-225. 10.1046/j.1523-536x.1999.00218.x.

Article   CAS   PubMed   Google Scholar  

Inch S: Incidence of mastitis among breastfeeding women from selected Oxfordshire general practitioners practices 1993-1994. 1996, Holloway, St Barts

Google Scholar  

Renfrew MJ, Woolridge MW, Ross McGill H: Enabling Women to Breastfeed. A Review of Practices which Promote or Inhibit Breastfeeding - with Evidence-Based Guidance for Practice. 2000, London, The Stationery Office

World Health Organization: Mastitis: Causes and Management. 2000, Geneva, WHO/FCH/ CAH/00.13

Fetherston C: Mastitis in lactating women: physiology or pathology?. Breastfeed Rev. 2001, 9: 5-12.

Amir LH, Forster D, McLachlan H, Lumley J: Incidence of breast abscess in lactating women: report from an Australian cohort. BJOG. 2004, 111: 1378-1381.

Article   PubMed   Google Scholar  

Thomsen AC, Espersen T, Maigaard S: Course and treatment of milk stasis, noninfectious inflammation of the breast, and infectious mastitis in nursing women. Am J Obstet Gynecol. 1984, 149: 492-495.

Matheson I, Aursnes I, Horgen M, Aabo O, Melby K: Bacteriological findings and clinical symptoms in relation to clinical outcome in puerperal mastitis. Acta Obstet Gynecol Scand. 1988, 67: 723-726.

Bertrand H, Rosenblood LK: Stripping out pus in lactational mastitis: a means of preventing breast abscess. Can Med Assoc J. 1991, 145: 299-306.

CAS   Google Scholar  

Osterman KL, Rahm VA: Lactation mastitis: bacterial cultivation of breast milk, symptoms, treatment and outcome. J Hum Lact. 2000, 16: 297-302.

Amir LH, Garland SM, Dennerstein L, Farish SJ: Candida albicans: is it associated with nipple pain in lactating women?. Gynecol Obstet Invest. 1996, 41: 30-34.

Livingstone VH, Willis CE, Berkowitz J: Staphylococcus aureus and sore nipples. Can Fam Physician. 1996, 42: 654-659.

CAS   PubMed   PubMed Central   Google Scholar  

von Eiff C, Becker K, Machka K, Stammer H, Peters G: Nasal carriage as a source of Staphylococcus aureus bacteremia. N Engl J Med. 2001, 344: 11-16. 10.1056/NEJM200101043440102.

Kluytmans J, Van Belkum A, Verbrugh H: Nasal carriage of Staphylococcus aureus: Epidemiology, underlying mechanisms, and associated risks. Clin Microbiol Rev. 1997, 10: 505-520.

Foxman B, D'Arcy H, Gillespie B, Bobo JK, Schwartz K: Lactation mastitis: occurrence and medical management among 946 breastfeeding women in the United States. Am J Epidemiol. 2002, 155: 103-114. 10.1093/aje/155.2.103.

Amir L: Breastfeeding and Staphylococcus aureus: three case reports. Breastfeeding Review. 2002, 10: 15-18.

PubMed   Google Scholar  

Gastelum DT, Dassey D, Mascola L, Yasuda LM: Transmission of community-associated methicillin-resistant Staphylococcus aureus from breast milk in the neonatal intensive care unit. Pediatr Infect Dis J. 2005, 24: 1122-1124. 10.1097/01.inf.0000189983.71585.30.

Ware JEJ, Gandek B, IQOLA Project Group: The SF-36 Health Survey: development and use in mental health research and the IQOLA project. Int J Ment Health. 1994, 23: 49-73.

Article   Google Scholar  

Amir LH, Lumley J: Women's experience of mastitis: 'I have never felt worse'. Aust Fam Physician. 2006, 35: 745-747.

Hosmer DW, Lemeshow S: Applied Logistic Regression. 2000, New York, John Wiley & Sons, Inc., 2nd Ed

Chapter   Google Scholar  

Bischoff WE, Wallis ML, Tucker KB, Reboussin BA, Sherertz RJ: Staphylococcus aureus nasal carriage in a student community: prevalence, clonal relationships, and risk factors. Infect Control Hosp Epidemiol. 2004, 25: 485-491. 10.1086/502427.

Berthelot P, Grattard F, Fascia P, Martin I, Mallaval FO, Ros A, Pozzetto B, Lucht F: Is nasal carriage of methicillin-resistant Staphylococcus aureus more prevalent among student healthcare workers? (Letter). Infect Control Hosp Epidemiol. 2004, 25: 364-365. 10.1086/503498.

Eveillard M, Martin Y, Hidri N, Boussougant Y, Joly-Guillou ML: Carriage of methicillin-resistant Staphylococcus aureus among hospital employees: prevalence, duration, and transmission to households. Infect Control Hosp Epidemiol. 2004, 25: 114-120. 10.1086/502360.

Peacock SJ, Justice A, Griffiths D, de Silva GD, Kantzanou MN, Crook D, Sleeman K, Day NP: Determinants of acquisition and carriage of Staphylococcus aureus in infancy. J Clin Microbiol. 2003, 41: 5718-5725. 10.1128/JCM.41.12.5718-5725.2003.

Article   PubMed   PubMed Central   Google Scholar  

Foxman B, Schwartz K, Looman SJ: Breastfeeding practices and lactation mastitis. Soc Sci Med. 1994, 38: 755-761. 10.1016/0277-9536(94)90466-9.

Wright KC, Feeney AM: The bacteriological screening of donated human milk: laboratory experience of British Paediatric Association's published guidelines. J Infect. 1998, 36: 23-27. 10.1016/S0163-4453(98)92946-2.

Eidelman AI, Szilagyi G: Patterns of bacterial colonization of human milk. Obstet Gynecol. 1979, 53: 550-552.

Wysham DN, Mulhern ME, Navarre GC, LaVeck GD, Kennan AL, Giedt WR: Staphylococcal infections in an obstetric unit. II Epidemiologic studies of puerperal mastitis. New Engl J Med. 1957, 257: 304-306.

Kawada M, Okuzumi K, Hitomi S, Sugishita C: Transmission of Staphylococcus aureus between healthy, lactating mothers and their infants by breastfeeding. J Hum Lact. 2003, 19: 411-417. 10.1177/0890334403257799.

Thomsen AC, Hansen KB, Moller BR: Leukocyte counts and microbiologic cultivation in the diagnosis of puerperal mastitis. Am J Obstet Gynecol. 1983, 146: 938-941.

Academy of Breastfeeding Medicine: Academy of Breastfeeding Medicine, Clinical Protocol Number 4: Mastitis. ABM News and Views. 30, 34-[ http://www.bfmed.org/ ]

Casewell MW: The nose: an underestimated source of Staphylococcus aureus causing wound infection. J Hosp Infect. 1998, 40: S3-S11. 10.1016/S0195-6701(98)90199-2.

Pre-publication history

The pre-publication history for this paper can be accessed here: http://www.biomedcentral.com/1471-2296/7/57/prepub

Download references

Acknowledgements

We would like to thank all the women who participated, the staff in the Breastfeeding Clinics, Maternal and Child Health Centres and Emergency Departments, in particular Colleen Stevens and Danielle Clifford.

Lisa Amir received a National Health and Medical Research Council Medical Public Health PhD Scholarship and a grant from the Medical Research Foundation for Women and Babies.

Author information

Authors and affiliations.

Mother & Child Health Research, La Trobe University, Melbourne, Australia

Lisa H Amir & Judith Lumley

Department of Microbiology and Infectious Diseases, The Royal Women's Hospital, Melbourne, Australia

Suzanne M Garland

You can also search for this author in PubMed   Google Scholar

Corresponding author

Correspondence to Lisa H Amir .

Additional information

Competing interests.

The author(s) declare that they have no competing interests.

Authors' contributions

The study was conducted by LHA as part of her PhD. SMG and JL supervised the project and contributed to the study design, analysis and writing.

Rights and permissions

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0 ), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Reprints and permissions

About this article

Cite this article.

Amir, L.H., Garland, S.M. & Lumley, J. A case-control study of mastitis: nasal carriage of Staphylococcus aureus . BMC Fam Pract 7 , 57 (2006). https://doi.org/10.1186/1471-2296-7-57

Download citation

Received : 07 June 2006

Accepted : 11 October 2006

Published : 11 October 2006

DOI : https://doi.org/10.1186/1471-2296-7-57

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

  • Private Health Insurance
  • Nasal Carriage
  • Express Breast Milk

BMC Primary Care

ISSN: 2731-4553

case study mastitis

  • Case report
  • Open access
  • Published: 25 April 2013

A lactating woman presenting with puerperal pneumococcal mastitis: a case report

  • Barbara Miedzybrodzki 1 &
  • Mark Miller 2  

Journal of Medical Case Reports volume  7 , Article number:  114 ( 2013 ) Cite this article

7035 Accesses

4 Citations

1 Altmetric

Metrics details

Introduction

Streptococcus pneumoniae is an uncommon etiologic agent in soft-tissue infections.

Case presentation

We report the case of a 35-year-old Caucasian woman who presented to our facility with puerperal pneumococcal mastitis, and review the only other three cases of pneumococcal mastitis described in the medical literature.

Conclusions

The roles of the various pneumococcal vaccines in preventing this disease are discussed.

Peer Review reports

Puerperal mastitis occurs most commonly during the first three to six months post-partum in breastfeeding mothers. Up to 25 percent of breastfeeding women have experienced at least one episode of mastitis, and recurrent mastitis has been reported in four to eight-and-a-half percent of breastfeeding women [ 1 ]. The most common causative organism of mastitis is Staphylococcus aureus . Other less common organisms include coagulase-negative staphylococci , beta-hemolytic streptococci (Lancefield groups A or B) , Escherichia coli , and Corynebacterium species [ 2 ]. Streptococcus pneumoniae is an extremely rare cause of mastitis. In this paper, we present the case of a healthy 35-year-old woman who presented to our facility with puerperal pneumococcal mastitis, and review the only three other cases of pneumococcal mastitis described in the medical literature.

A literature review using a MEDLINE search from 1950 to July 2010 revealed only two cases of puerperal mastitis and one case of non-puerperal mastitis caused by S. pneumoniae (Table  1 ). The first case of pneumococcal mastitis was described by DiNubile et al . in 1991 in a 23-year-old woman with systemic lupus erythematosus who was being treated with prednisone but was not lactating [ 3 ]. She presented with an abscess of the left breast and the aspirate revealed S. pneumoniae and Bacteroides fragilis. The second case, described by Wüst et al . in 1995, was in a healthy 38-year-old woman breastfeeding her nine-month-old daughter [ 4 ]. In that case, serotyping was performed on a nasal and throat swab taken from the child as well as from the breast. All three cultures revealed S. pneumoniae serotype 6B, which the authors reported as being the second most frequent type found in the region at that time. The third case was published by Kragsbjerg et al . in 1995, concerning a 38-year-old woman who presented with purulent secretions from the breast while she was breastfeeding her four-month-old child [ 5 ]. Cultures taken from the breast and from the nasopharynx of the child revealed the same serotype of S. pneumoniae.

A 35-year-old Caucasian woman who was breastfeeding her eight-month-old twins presented to our facility with a three-day history of fronto-parietal headache, fever, general malaise, and two episodes of syncope on the day of admission. On further questioning, she also reported increasing pain in her right breast over the last 24 hours.

She appeared toxic and was febrile (39.0°C axillary temperature). A physical examination revealed an exquisitely tender right breast that was erythematous and indurated in the right lower lateral quadrant. There was, however, no area of fluctuance although purulent milky secretions could be expelled from the right nipple with mild peri-areolar pressure. These secretions were cultured. Slightly tender right axillary adenopathy was also present.

The results of laboratory investigations were unremarkable, including a normal blood count, except for the presence of a left shift with 80 percent neutrophils (total white blood cell count of 9.8×10 9 cells/L). Several diagnostic investigations were performed, including a lumbar puncture, cerebral computed tomography (CT) and magnetic resonance imaging (MRI) scans, and blood cultures, all of which yielded normal results. A clinical diagnosis of puerperal mastitis was made, and treatment with intravenous vancomycin and cefazolin was initiated. Our patient continued pumping her breast milk. On the day after admission, increased amounts of pus were noted draining from the right nipple with each breast pumping. Our patient’s fever and rigors resolved within 48 hours. Culture of the breast secretions at the time of admission revealed heavy pure growth of S. pneumoniae , polysaccharide serotype 19A, which was susceptible to penicillin, cephalosporins, macrolides, tetracyclines and vancomycin. Her hospital course was uncomplicated and she was discharged home on day three post-admission with a 10-day course of oral cefadroxil. Neither of her babies showed any evidence of a respiratory tract infection prior to our patient’s illness; nasopharyngeal culture tests from the babies were not performed as they were at home with the father and unavailable for culture sampling.

Pneumococcal mastitis is an extremely rare entity and, to the best of our knowledge, there have been only three other case reports in the literature, two of which were puerperal. S. pneumoniae is a leading cause of respiratory tract infections and meningitis in both children and adults. It is, however, a rare cause of skin and soft-tissue infections and the cases reported are mostly described in patients who have some degree of immunosuppression [ 6 ]. Our patient, whose case we present here, was a healthy 35-year-old immunocompetent woman and there were no signs of any connective tissue diseases or other coincidental health issues.

Although neither of her babies showed any evidence of a respiratory tract infection prior to our patient’s illness, and testing of the babies was not undertaken due to their unavailability, it appears that the most probable way in which the mother became infected with S. pneumoniae serotype 19A was from one or both of the nasopharyngeal tracts of the babies during breastfeeding. In both of the previous case reports [ 4 , 5 ], the breastfed babies had tested positive on nasopharyngeal swabs and showed symptoms of mild respiratory tract infections, which is consistent with our interpretation of the mode of transmission of the S. pneumoniae in mastitis. Our patient's twin babies were both routinely vaccinated at two and four months of age with Prevnar-7® (Wyeth, Collegeville, PA, USA), which contains capsular antigens of S. pneumoniae serotypes 4, 6B, 9V, 14, 18C, 19F, and 23F. Thus, the serotype 19A S. pneumoniae isolated in our patient was not part of the seven-valent pneumococcal conjugate vaccine administered to children in the province of Quebec, where our patient resided at the time of her illness. Current Quebec immunization guidelines recommend vaccination of healthy babies with a pneumococcal seven-valent conjugate vaccine (Prevnar-7®) to be given in three doses administered at two, four and 12 months of age [ 7 ]. However, since the introduction of Prevnar-7®, there has been growing concern of the development and spread of the pneumococcal serotypes not covered in the vaccine. A recent review by Reinert et al . describes global indicators showing that serotype 19A is now the most prevalent as well as the most increasingly resistant S. pneumoniae serotype in invasive infections [ 8 ]. The most prevalent serotypes involved in invasive disease in Canada at the time of our patient’s presentation were (in descending order): 19A, 7F, 18C, 6A, 22F, 4, 5, 3 and 23B [ 9 ].

Given these findings, the new 13-valent vaccine (Prevnar-13®) that has recently been licensed in Canada, will likely reduce the increasingly prevalent infection rate from the 19A strain of S. pneumoniae . This new vaccine contains the same antigens as Prevnar-7® with six additional capsular antigens of serotypes 1, 3, 5, 6A, 7F and 19A [ 10 ], which together comprise 13 of the 91 S. pneumoniae serotypes described thus far [ 8 ].

This case report highlights the fact that puerperal mastitis may be caused by unusual bacteria, including S. pneumoniae. Immunization of babies with effective pneumococcal vaccines should decrease the incidence of pneumococcal puerperal infections even further, as well as other invasive pneumococcal infections that may be similarly transmitted from baby to mother.

Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Foxman B, D'Arcy H, Gillespie B, Bobo JK, Schwartz K: Lactation mastitis: occurrence and medical management among 946 breastfeeding women in the United States. Am J Epidemiol. 2002, 155: 103-114. 10.1093/aje/155.2.103.

Article   PubMed   Google Scholar  

World Health Organization: Mastitis: Causes and Management. WHO/FCH/CAH/00.13. 2000, Geneva, Switzerland: WHO

Google Scholar  

DiNubile MJ, Albornoz A, Stumacher RJ, Van Uitert BL, Paluzzi SA, Bush LM, Nelson SL, Myers AR: Pneumococcal soft-tissue infections: possible association with connective tissue diseases. J Infect Dis. 1991, 163: 897-900. 10.1093/infdis/163.4.897.

Article   CAS   PubMed   Google Scholar  

Wüst J, Rutsch M, Stocker S: Streptococcus pneumoniae as an agent of mastitis. Eur J Clin Microbiol Infect Dis. 1995, 14: 156-157. 10.1007/BF02111883.

Kragsbjerg P, Noren T, Soderquist B: Deep soft-tissue infections caused by Streptococcus pneumoniae . Eur J Clin Microbiol Infect Dis. 1995, 14: 1002-1004. 10.1007/BF01691383.

Garcia-Lechuz JM, Cuevas O, Castellares C, Perez-Fernandez C, Cercenado E, Bouza E: Streptococcus pneumoniae skin and soft tissue infections: characterization of causative strains and clinical illness. Eur J Clin Microbiol Infect Dis. 2007, 26: 247-255. 10.1007/s10096-007-0283-7.

Public Health Aganecy of Canada: Publicly funded Immunization Programs in Canada - Routine Schedule for Infants and Children (including special programs and catch-up programs). http://www.phac-aspc.gc.ca/im/ptimprog-progimpt/table-1-eng.php ,

Reinert RR, Jacobs MR, Kaplan S: Pneumococcal disease caused by serotype 19A: review of the literature and implications for future vaccine development. Vaccine. 2010, 28: 4249-4259. 10.1016/j.vaccine.2010.04.020.

Griffith A, Demczuk W, Martin I, Shane A, Tyrrell G, Gilmour MW, the Canadian Public Health Laboratory Network: Distribution of invasive pneumococcal serotypes in Canada: 2010–2011. Abstract #K4. 2012, Vancouver, Canada: AMMI Canada - CACMID Annual Conference

Bryant KA, Block SL, Baker SA, Gruber WC, Scott DA, PCV13 Infant Study Group: Safety and immunogenicity of a 13-valent pneumococcal conjugate vaccine. Pediatrics. 2010, 125: 866-875. 10.1542/peds.2009-1405.

Download references

Acknowledgements

We would like to thank our patient for allowing use of her clinical and laboratory information for publication. No financial support has been given for this report.

Author information

Authors and affiliations.

Division of Internal Medicine, Jewish General Hospital, 3755 Cote-Ste-Catherine, Montreal, Quebec, H3T 1E2, Canada

Barbara Miedzybrodzki

Division of Infectious Diseases, Jewish General Hospital, 3755 Cote-Ste-Catherine, Montreal, Quebec, H3T 1E2, Canada

Mark Miller

You can also search for this author in PubMed   Google Scholar

Corresponding author

Correspondence to Mark Miller .

Additional information

Competing interests.

The authors declare that they have no competing interests.

Authors’ contributions

EM performed the literature review. Both authors collected, analyzed and interpreted the clinical and microbiologic data from our patient. Both authors wrote the manuscript and read and approved the final version.

Rights and permissions

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0 ), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Reprints and permissions

About this article

Cite this article.

Miedzybrodzki, B., Miller, M. A lactating woman presenting with puerperal pneumococcal mastitis: a case report. J Med Case Reports 7 , 114 (2013). https://doi.org/10.1186/1752-1947-7-114

Download citation

Received : 25 November 2012

Accepted : 26 March 2013

Published : 25 April 2013

DOI : https://doi.org/10.1186/1752-1947-7-114

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

  • Pneumococcal infection
  • Puerperal mastitis
  • Streptococcus pneumoniae
  • Pneumococcal vaccine

Journal of Medical Case Reports

ISSN: 1752-1947

  • Submission enquiries: Access here and click Contact Us
  • General enquiries: [email protected]

case study mastitis

  • Open access
  • Published: 02 May 2022

A case management model for patients with granulomatous mastitis: a prospective study

  • Yuan Deng 1 , 2 ,
  • Ying Xiong 1 ,
  • Ping Ning 1 ,
  • Xin Wang 2 ,
  • Xiao-Rong Han 1 ,
  • Guo-Fang Tu 2 &
  • Pei-Yu He 1  

BMC Women's Health volume  22 , Article number:  143 ( 2022 ) Cite this article

3131 Accesses

3 Citations

1 Altmetric

Metrics details

Granulomatous mastitis (GM) is a chronic inflammatory mastitis disease that requires long-term treatment and has a high recurrence rate. Case management has been proven to be an effective mechanism in assisting patients with chronic illness to receive regular and targeted disease monitoring and health care service. The aim of this study was to investigate the application of a hospital-to-community model of case management for granulomatous mastitis and explore the related factors associated with its recurrence.

This was a prospective study on patients with granulomatous mastitis based on a case management model. Data on demographic, clinical and laboratory information, treatment methods, follow-up time, and recurrence were collected and analyzed. The eight-item Morisky Medication Adherence Scale (MMAS-8) was used to investigate patients' adherence to medications. Logistic regression models were built for analysis of risk factors for the recurrence of granulomatous mastitis.

By October 2021, a total of 152 female patients with a mean age of 32 years had undergone the entire case management process. The mean total course of case management was 24.54 (range 15–45) months. Almost all the patients received medication treatment, except for one pregnant patient who received observation therapy, and approximately 53.9% of the patients received medication and surgery. The overall recurrence rate was 11.2%, and “high” medication adherence (RR = 0.428, 95% CI 0.224–0.867, P  = 0.015) was significantly associated with a lower rate of recurrence, while the rate of recurrence with a surgical procedure + medication was higher than that with medication alone (RR = 4.128, 95% CI 1.026–16.610, P  = 0.046).

A case management model for patients with granulomatous mastitis was applied to effectively monitor changes in the disease and to identify factors associated with disease recurrence. “Low” medication adherence was a significant risk factor for the recurrence of granulomatous mastitis. Patients treated with medication and surgery were more likely to experience recurrence than those treated with medication alone. The optimal treatment approach should be planned for granulomatous mastitis patients, and patient medication adherence should be of concern to medical staff.

Peer Review reports

Granulomatous mastitis (GM) was first reported as a chronic inflammatory disease of the breast by Kessler and Wolloch in 1972 [ 1 ], and accounts for approximately 1.8% of benign breast diseases [ 2 ]. The main clinical presentation is a palpable, painful breast lump with concomitant skin erythema, nipple retraction, sinus tract formation, cellulitis changes, and axillary adenopathy formation [ 3 , 4 , 5 ], and in severe cases, there are usually multiple coexisting focal abscesses with skin inflammation and ulceration [ 5 ]. According to the severity of the disease, GM is clinically classified into mass, abscess, and refractory types [ 6 ]. Patients often endure a long disease course, as well as changes in breast appearance caused by the disease, which has serious physical and psychological effects on patients [ 7 ]. With only 2.4 per 100,00 incidences reported by the Centers for Disease Control and Prevention in 2009, most countries have not conducted large epidemiological surveys for GM due to the rarity of the disease [ 8 ]. To date, the etiology of GM is unknown and may be associated with a history of pregnancy, autoimmune disease, breast trauma, hyperprolactinemia, and infection [ 7 , 9 ]. The disease progresses rapidly with a recurrent or prolonged natural course, which has a high recurrence rate of 5%-50%, and is commonly seen in young women with a history of breastfeeding and childbirth [ 3 , 10 , 11 , 12 ]. As recently reported, there are racial differences in this disease, and the incidence of GM in Middle Eastern countries (Egypt, Turkey, Iran) and Spain is higher than that in Western countries (UK, USA, New Zealand) [ 13 , 14 , 15 ]. A large number of cases of GM have been described, mainly from Asian and Mediterranean countries, such as China, Iran, and Turkey [ 16 , 17 ]. However, there is no consensus on the management of GM and no gold standard regarding the diagnosis and treatment of the disease [ 4 ]. Currently, the main treatment include observation, medication therapy (steroids, antibiotics, methotrexate (MTX), and anti-molecular bacilli) and/or operative interventions (abscess incision and drainage, simple mass excision, enlarged mammary mass excision, etc.) [ 15 , 18 ], and medication therapy is the most commonly used treatment. The toxic side effects of long-term medication use have a significant impact on patients' quality of life, resulting in poor compliance with drug use, therefore, timely observation of medication use and changes in the breasts is essential to achieve good recovery rates for GM patients [ 11 , 18 , 19 , 20 ].

Recently, one approach to managing care that has gained wide popularity is case management [ 21 ], which promote access to provide patients with regular and targeted disease monitoring and health guidance through follow-up visits and WeChat consultations in China (WeChat is a mobile chat software by the Chinese company Tencent, in which patients can quickly consult with medical staff by sending voice messages, videos, pictures and texts over the internet quickly) [ 22 ]. Nurse specialists are responsible for the overall coordination, management, and continuity of care for a specific treatment or intervention to meet the health needs of an individual, reduce health care costs and improve the quality of service [ 23 , 24 ]. Currently, it is known that case management is widely applied for patients with breast disease, especially breast cancer [ 25 , 26 ], but it is rarely to applied for GM patients. Based on the characteristics of the disease, which is mostly treated and followed up in outpatients, a tailored model should be developed that it enables health providers monitor the condition changes of GM patients from outpatient to community to inpatient settings. A hospital-to-community model of case management, which allows cases managers to track and manage the treatment of GM patients from hospital to community settings, was described by Lamb in 1992, and includes the following five basic activities of case management: (1) assessment, (2) planning, (3) linking, (4) monitoring, and (5) advocacy [ 27 ]. Since January 2018, a tailored model for GM based on a hospital-to-community model, which can provide patients with full management and seamless health care services, has been explored and practiced in Chengdu Women's and Children's Central Hospital.

To better observe the development of this disease with treatment and identify some of the factors associated with its recurrence, we used a hospital-to-community-based model of case management to monitor the condition changes of GM patients. Prospective studies can provide more effective strategies and optimal approaches to prevent the recurrence of disease.

Materials and methods

Study design and participants.

A prospective study on patients with granulomatous mastitis based on the case management model was undertaken between January 2018 and November 2020 in the Breast Unit of Chengdu Women’s and Children’s Central Hospital. According to the characteristics of the disease, the whole case management process, presented in Fig.  1 , was divided into four key stages, including the diagnostic, conservative, perioperative, and follow-up periods. The entire process was led by case managers and tailored for patients, including the evaluation, planning, integration, implementation, and evaluation of treatment plans. Participants were followed up through the whole process. The case closure time was defined as the time when a patient was free of relapse during the 1-year follow-up period after the discontinuation of medication or surgery.

figure 1

the algorithm for the case management of granulomatous mastitis

In the diagnostic stage, the case managers mainly based their decisions on clinical symptoms, regardless of whether a register of the initial medical history was created including age, pregnancy history, disease history, onset time, onset trigger, and contact phone number. A patient’s diagnosis of granulomatous mastitis was confirmed by the results of a pathological examination by core needle biopsy, and then a case management file was established. In the conservative treatment stage, case managers mainly performed the following: (1) followed up and recorded the results of ultrasounds, abnormal laboratory tests and breast signs, and explained the precautions and methods of medication administration according to a doctor's prescription; (2) surveyed GM patients for medication adherence at 2 months of drug use by the eight-item Morisky Medication Adherence Scale (MMAS-8) [ 28 ]; (3) distributed notes of disease considerations related to diet, sleep, behaviors, etc., as shown in Table 1 [ 6 , 29 , 30 ]; and (4) established a contact platform for GM patients to understand and observe the changes in their breasts during treatment, while being given psychological support and guidance at home. In the perioperative and follow-up periods, the case managers recorded the patients' surgery, medication, follow-up time and recurrence information.

In this study, qualifications for case managers were as follows: (1) nurses with bachelor's degree or above; (2) nurses with an intermediate title or above; (3) nurses with 5 years of experience or more in the breast department; (4) nurses who had received the training, which included the case management process, communication and health promotion skills; (5) nurses who were required to rotate through the breast clinic, ultrasound and pathology department, wound care unit and operating room, and (6) nurses who had passed the hospital examination for case management. All patients who received case management were eligible for inclusion if they were older than 18 years, had clinical breast symptoms, and had a confirmed diagnosis by core needle biopsy. Patients were ineligible if they had other complications of the breast and had been treated at other institutions. The study was approved by the Ethics Committee of Chengdu Women's and Children's Central Hospital (No. B2019 (13)). All participants signed an informed consent form.

Case definition

Histopathological examination is a necessary and gold-standard method for the diagnosis of granulomatous mastitis [ 31 ], so a definitive diagnosis of GM was largely accomplished with core needle biopsy in this study. The disease may be locally invasive with a risk of recurrence, and recurrence rates of 5 to 50% have been observed by various studies in recent years [ 10 , 11 , 12 ]. The following definition of recurrence was used in this study: the detection of new lesion (s) within the range of the primary location or any other part of the ipsilateral breast 1 month following the termination of therapy.

Medication adherence was measured using the eight-item Morisky Medication Adherence Scale (MMAS-8) [ 28 ], which was translated into a Chinese scale by Lin Chen et al. [ 32 ]; this scale has high reliability and validity and has been widely used in studies of various chronic diseases in China [ 32 , 33 ]. Three levels of adherence were considered based on the following scores: 0 to < 6 (low); 6 to < 8 (medium); and 8 (high). In a meta-analysis by Lei et al. [ 34 ], oral drug therapy was an effective treatment modality or GM patients in receiving both surgical and conservative treatment. According to the relevant literature, steroids are the most prominent drugs for GM, which usually lasts from 3 to 12 months, with a minimum of 2 months [ 35 , 36 , 37 , 38 ]. To survey as many patients as possible, we chose to conduct a survey of medication adherence at 2 months of medication use.

Statistical analysis

The statistical software package SPSS for Windows, version 19.0 (SPSS Inc., Chicago, IL) was used for statistical analysis. Clinical characteristics were described using the mean ± standard deviation, the mean (range) or numbers (and percentages) as appropriate. Continuous variables were compared between patients with and without recurrence using one-way ANOVA, while categorical variables were compared using the Chi-square test and Fisher's exact tests. Logistic regression models were built for the analysis of risk factors for the recurrence of GM.

Patient characteristics

In this study, 204 symptomatic patients with granulomatous mastitis were initially included in the diagnostic stage between January 2018 and November 2020. However, 4 patients were diagnosed with breast cancer, 8 dropped out, and 40 were still undergoing case management. Ultimately, 152 patients had completed case management by September 2021. Table 2 shows that the mean age of the patients was 32 years (range 22–48). It was observed that 71 (46.7%) patients had normal BMI, while 64 (47,4%) patients had a BMI higher than 25, and were considered overweight or obese. It was detected that the period in which GM was most frequently seen was the first 2–5 years after birth, with 94 patients (61.8%), followed by 30 patients (19.7%) diagnosed 0–2 years after birth (4 patients were breastfeeding), and 15 patients (9.9%) diagnosed during pregnancy. Accompanying diseases were found in only 28 (18.5%) patients, such as diabetes mellitus, thyroid disease, psychoses, hypertension, and hyperprolactinemia, accounting for the highest percentage of 13.8% of all comorbidities.

On physical examination, the most common finding was a palpable mass with pain (98.7%); 38.8% of the patients had a breast abscess, 75% suffered from skin lesions, and approximately 5% had fistulas and erythema nodosum (Table 2 ). Based on clinical symptoms, the disease was typed as the mass (74, 48.7%), abscess (66, 43.4%), and refractory types (12, 7.9%). Unilateral involvement was observed the most in 140 (92.1%) patients. In this study, 30.96% of the patients reported that they had bad behaviors a week before disease onset, including breast trauma (8.6%), excitant food (14.47%), and staying up all night (7.89%).

Patient treatments

Table 3 shows the different treatments that were administered. Of the 152 patients, only 1 (0.7%) recovered under observation without treatment, 82 (53.9%) recovered with medication and surgery, and 69 (45.4%) recovered with medical treatment alone. In the courses of medications, 65 (42.8%)patients chose systemic steroids alone, 21 (13.7%) patients chose tubercle bacillus drugs alone, and 65 (42.8%) patients required a combination or change of the drug regimen due to ineffective treatment or drug side effects including erythema nodosum (5.3%), skin rash (5.3%), abnormal index of liver function (7.2%), abnormal uric acid (2.0%) and edema on the lips and face (0.7%).

Patient follow-up visits

The mean follow-up time was 25.55 months (range 15–45) for the patients treated with medication and surgery, while it was 23.83 months (range 17–36) for the patients treated with medication alone. There was no statistically significant difference between the groups ( p  = 0.570). The recurrence rate in the series was determined to be as 11.2% with 17 patients experiencing recurrence. At 2 months of initial medication use, the medication adherence outcome of the GM patients was “high” for 59 patients (39%), “medium” for 70 patients (46.4%), and “low” for 22 patients (14.6%), as shown in Table 4 .

Factors associated with recurrence

All statistically significant variables ( P < 0.05) related to BMI, treatments, medication use and medication adherence (Table 5 ) were included in the multivariable logistic regression model. The results of the multivariable analysis are shown in Table 6 . Surgical procedure and drug treatment (RR = 4.128, 95% CI 1.026–16.610, P  = 0.046) were independently associated with an increased recurrence risk of granulomatous mastitis. In contrast, “high” medication adherence (RR = 0.428, 95% CI 0.224–0.867, P  = 0.015) was associated with decreased recurrence risk.

Discussion and conclusion

This is the first study to report a case management model applied for GM patients. Although GM is a benign disease, its recurrence, one of the main challenges in the management of patients with the disease, has been reported to occur in 5%-50% of patients [ 10 , 11 , 12 ]. In our study, the recurrence rate of 11.2% is low in this range. Seventeen patients experienced recurrence, including ten with new lesions in the ipsilateral breast and seven with new lesions in the contralateral breast.

In recent years, the prevalence of granulomatous mastitis has been rapidly increasing, and the most affected patients are women of childbearing age [ 39 ]. In two studies, Freeman et al. reported that up to 86% of GM patients had a history of pregnancy in the past 5 years [ 38 ]. Prasad et al. reported that 73 patients with GM had a mean age of approximately 33 years and a history of childbirth 4.6 years before mastitis on average [ 40 ]. In our study, which had similar characteristics to previously reported studies, the median age of the patients was 32 years (range 22–48), 119 patients had a history of childbirth within the last 5 years, 15 patients had concurrent pregnancy, and 4 patients were currently breastfeeding. These findings indicated that hormones play an important role and may be related to the secretion theory, which has an important place in the pathophysiology of GM [ 12 ]. It has been postulated that GM results from a localized autoimmune response to the retained or extra vacated fat- or protein-rich secretions in the breast ducts in women of childbearing age due to previous hyperprolactinemia [ 41 ]. Therefore, the breast care for women of childbearing age deserves our attention.

GM patients mostly have mass and pain symptoms, and skin lesions and abscesses can be observed in mass localization. Findings such as fistula, erythema nodosum, and nipple or skin retraction can also be observed [ 1 , 2 , 35 ]. In many studies, the most common reported complaint at the time of the initial visit was a unilateral painful breast mass [ 35 , 42 ]. Similarly, 98.7% of the patients had mass and pain complaints, and 92.1% of the patients presented with a unilaterally affected breast. The case managers made initial judgments and provided tentative guidance based on clinical presentations. At the initial visit, there were mass (74, 48.7%), abscess (66, 43.4%), and refractory types (12, 7.9%), which were not associated with recurrence in the later stages ( P  = 0.2). As the disease progressed, 10 mass type cases were actually abscess type cases, and 4 abscess type cases were actually refractory type cases. An important consideration for case managers is the care of the affected breast (shown in Fig.  2 and Fig.  3 ). Wound care should consist of managing drainage from fistulae with gauze and other nonadherent dressings. Tape should be avoided due to further abrasion and irritation of the skin [ 43 ]. Meanwhile, if a patient has a superficial abscess, a case manager should percutaneously perform puncture aspiration, and determine how deep the abscess is, while a mammographer, assisted by ultrasound guidance, performs puncture drainage, to create a path for the drainage of secretions and reduction of pressure in the inflamed area due to the accumulation of inflammatory fluid.

figure 2

The effect of medical and surgical treatment in the case management. The underlined part of the figure shows the scope of the lesion located by ultrasound. a Before the treatment. b After the steroids treatment for 4 months and before surgical treatment. c Before stopping the steroids treatment and after right breast lesion excision for 1.5 months

figure 3

The effect of medical treatment in the case management. a Before the medical treatment and wound care. b After the tubercle bacillus drug and wound care for 14 months

Comparing the most recent publications on GM to older studies, there is no new information on this benign breast disease. Therefore, the best management of this disease is still unclear [ 11 , 12 ]. The usual treatment for GM is close observation, medical treatment, surgical management, or a combination of medication and surgery [ 3 , 15 , 44 ]. In the present study, only 1 (0.7%) patient recovered under observation, 82 (53.9%) recovered with medication and surgery (as shown in Fig.  2 ), and 69 (45.4%) recovered with medication alone (as shown in Fig.  3 ). Multivariate analysis revealed that medication and surgery was significantly associated with recurrence (RR = 4.128, 95% CI [1.026–16.610], P  = 0.0046) (Table 6 ). Regarding the cause of recurrence, previous studies have ascribed the incompleteness of excision to the failure of surgical treatment, or inconsistent follow-up times. In this study, case managers assessed changes in the size of the breast mass and the proportion of the mass to the breast size and considered whether the patients could undergo surgical excision with minimal impact on the aesthetics of the breast. Breast lesion excision by minimally invasive surgery or open surgery was applied, which may have a risk of incomplete surgical excision. Akcan et al. and Yabanoğlu et al. reported that complete excision of the breast lesion or wide excision with or without medication achieved low recurrence rates [ 38 , 45 ]; however, it is possible to cause damage to the breast due to the excessive removal of tissues. Therefore, the biggest problem with surgical treatment is the contradiction between the surgical effect and the postoperative aesthetic effect. Whether the surgical procedure that is chosen which increases the recurrence rate of GM requires further investigation.

Our study demonstrated that medical treatment is the most prevalent treatment, regardless of whether it is coupled with surgical treatment. Drug therapies have numerous side effects, such as Cushion's syndrome, skin rash, abnormal liver enzymes and abnormal uric acid and [ 46 ]. In our study, 8 (5.3%) patients suffered from skin rash, 11 (7.2%) had abnormal liver enzymes, 3 (2.0%) had abnormal uric acid, and 1 (0.7%) had edema on the lips and face (as shown in Table 3 ). In this stage, case managers served as a treatment team by linking physicians, pharmacists, dermatologists, obstetricians, and general practitioners. They immediately communicated with the multidisciplinary team, and then guided patients regarding their medications, and finally, most of the side effects disappeared within 1 week.

To the best of our knowledge, there are no studies investigating medication adherence in GM patients. In our study, it shown that the MMAS-8 was completed by 154 patients, with 39% who had high adherence, 46.4% who had medium adherence, and 14.6% who had low adherence. As a result of case manager guidance, the “low” medication adherence rate of GM patients was much lower than that of 30% and 50% of reported for adults with chronic disease [ 47 , 48 ]. Furthermore, “high” medication adherence (RR = 0.428, 95% CI 0.224–0.867, P  = 0.015) at 2 months after initial medication use was significantly associated with a lower rate of recurrence in multivariate analysis. At the initial stage, the case managers paid more attention to the changes in the patients’ breast symptoms than to patient medication adherence, and the guidance and supervision of medical staff to patient medication need improvement. Currently, several reports have demonstrated the importance of regular visits to a physician, adequate patient contact time in clinical practice, and patient education to improve medication adherence to treatment [ 49 , 50 ].

Recent evidence indicates that the occurrence and recurrence of GM is associated with the Corynebacterium species, especially Corynebacterium kroppenstedtii [ 39 , 51 ]. In our study, samples of C. kroppenstedtii were obtained by ultrasound guidance for the puncture or biopsy of breast abscesses or hypoechoic masses. Breast pus or tissues were used for bacterial culture, and the positive rate of C. kroppenstedti was only 23.69% (36/152). In different studies, the positive rate of C. kroppenstedtii varies considerably, mainly due to the detection techniques. Li et al. [ 52 ] reported that nanopore sequencing showed accurate C. kroppenstedti detection over the culture method in GM patients. Therefore, the need to improve detection techniques for the Corynebacterium species will facilitate the study of the relationship between GM and bacteria.

In this study, the results showed that 22 (14.47%) patients had excitant food before the onset of GM. The recent literature reports that bacterial interactions have been confirmed between the breast and gut [ 53 , 54 ]. Li et al. hypothesized that imbalances among the external environment, host, and microbiota lead to the occurrence of GM as follows: External factors disturb the balance between the immune microenvironment and breast flora and induce the release of inflammatory factors and milk secretion, resulting in damage to the mammary epithelium. The positive feedback between the immune and inflammatory reactions eventually induces GM [ 13 ]. The consumption of stimulating foods may disrupt the intestinal flora and induce inflammation. Therefore, patients with GM should be given information regarding disease considerations related to diet, sleep, behaviors, etc., as shown in Table 1 .

Our study has several limitations. First, it cannot be confirmed whether interesting factors such as dietary and lifestyle habits are related to the occurrence and recurrence of GM. Second, the effects of this case management model cannot be assessed by this study. Therefore, there are several directions for our next work, including developing targeted strategies based on the case management model and exploring the effectiveness of this model in GM patients.

In conclusion, this study identified some factors associated with the recurrence of the disease under a case management model. “Low” medication adherence was a significant risk factor for the recurrence of granulomatous mastitis. The patients treated with medication and surgery did not have a reduced recurrence rate compared to those treated with medication alone.

Availability of data and materials

The datasets generated and/or analyzed during the current study are not publicly available due to restrictions related to confidentiality i.e., they contain information that could compromise the privacy of research participants, but are available from the corresponding author on reasonable request.

Kessler E, Wolloch Y. Granulomatous mastitis: a lesion clinically simulating carcinoma. Am J Clin Pathol. 1972;58(6):642–6. https://doi.org/10.1093/ajcp/58.6.642 .

Article   CAS   PubMed   Google Scholar  

Baslaim MM, Khayat HA, Al-Amoudi SA. Idiopathic granulomatous mastitis: a heterogeneous disease with variable clinical presentation. World J Surg. 2007;31(8):1677–81. https://doi.org/10.1007/s00268-007-9116-1 .

Article   PubMed   Google Scholar  

Li J. Diagnosis and treatment of 75 patients with idiopathic lobular granulomatous mastitis. J Investig Surg. 2019;32(5):414–20. https://doi.org/10.1080/08941939.2018.1424270 .

Article   Google Scholar  

Steuer AB, Stern MJ, Cobos G, Castilla C, Joseph KA, Pomeranz MK, Femia AN. Clinical characteristics and medical management of idiopathic granulomatous mastitis. JAMA Dermatol. 2020;156(4):460–4. https://doi.org/10.1001/jamadermatol.2019.4516 .

Article   PubMed   PubMed Central   Google Scholar  

Lai EC, Chan WC, Ma TK, Tang AP, Poon CS, Leong HT. The role of conservative treatment in idiopathic granulomatous mastitis. Breast J. 2005;11(6):454–6. https://doi.org/10.1111/j.1075-122X.2005.00127.x .

Wang Qi, Yu H. Precision diagnosis and treatment of granulomatous mastitis. Chin J Breast Dis (Electron Vers). 2017;03:129–31.

Google Scholar  

Wang J, Xu H, Li Z, Li F, Yang Y, Yu X, Jiang D, Xing L, Sun H, Shao M. Pathogens in patients with granulomatous lobular mastitis. Int J Infect Dis. 2019;81:123–7. https://doi.org/10.1016/j.ijid.2019.01.034 .

Centers for Disease Control and Prevention (CDC). Idiopathic granulomatous mastitis in Hispanic women–Indiana, 2006–2008. MMWR Morb Mortal Wkly Rep. 2009;58(47):1317–21.

Al-Khaffaf B, Knox F, Bundred NJ. Idiopathic granulomatous mastitis: a 25-year experience. J Am Coll Surg. 2008;206(2):269–73. https://doi.org/10.1016/j.jamcollsurg.2007.07.041 .

Aghajanzadeh M, Hassanzadeh R, Alizadeh Sefat S, Alavi A, Hemmati H, et al. Granulomatous mastitis: Presentations, diagnosis, treatment and outcome in 206 patients from the north of Iran. Breast. 2015;24(4):456–60. https://doi.org/10.1016/j.breast.2015.04.003 .

Klipfel N, Grant E, Iyengar G. Granulomatous lobular mastitis: imaging, diagnosis, and treatment. AJR Am J Roentgenol. 2009;193(2):574–81. https://doi.org/10.2214/AJR.08.1528 .

Lin CH, Hsu CW, Tsao TY, Chou J. Idiopathic granulomatous mastitis associated with risperidone-induced hyperprolactinemia. Diagn Pathol. 2012;5(7):2. https://doi.org/10.1186/1746-1596-7-2 .

Article   CAS   Google Scholar  

Barreto DS, Sedgwick EL, Nagi CS, Benveniste AP. Granulomatous mastitis: etiology, imaging, pathology, treatment, and clinical findings. Breast Cancer Res Treat. 2018;171(3):527–34. https://doi.org/10.1007/s10549-018-4870-3 .

Helal TE, Shash LS, Saad El-Din SA, Saber SM. Idiopathic granulomatous mastitis: cytologic and histologic study of 65 Egyptian patients. Acta Cytol. 2016;60(5):438–44. https://doi.org/10.1159/000448800 .

Sheybani F, Naderi HR, Gharib M, Sarvghad M, Mirfeizi Z. Idiopathic granulomatous mastitis: long-discussed but yet-to-be-known. Autoimmunity. 2016;49(4):236–9. https://doi.org/10.3109/08916934.2016.1138221 .

Al Manasra AR, Al-Hurani MF. Granulomatous mastitis: a rare cause of male breast lump. Case Rep Oncol. 2016;9(2):516–9. https://doi.org/10.1159/000448990 .

Velidedeoglu M, Kilic F, Mete B, Yemisen M, Celik V, Gazioglu E, Ferahman M, Ozaras R, Yilmaz MH, Aydogan F. Bilateral idiopathic granulomatous mastitis. Asian J Surg. 2016;39(1):12–20. https://doi.org/10.1016/j.asjsur.2015.02.003 .

Akbulut S, Yilmaz D, Bakir S. Methotrexate in the management of idiopathic granulomatous mastitis: review of 108 published cases and report of four cases. Breast J. 2011;17(6):661–8. https://doi.org/10.1111/j.1524-4741.2011.01162.x .

Hur SM, Cho DH, Lee SK, Choi MY, Bae SY, Koo MY, Kim S, Choe JH, Kim JH, Kim JS, Nam SJ, Yang JH, Lee JE. Experience of treatment of patients with granulomatous lobular mastitis. J Korean Surg Soc. 2013;85(1):1–6. https://doi.org/10.4174/jkss.2013.85.1.1 .

Mahlab-Guri K, Asher I, Allweis T, Diment J, Sthoeger ZM, Mavor E. Granulomatous lobular mastitis. Isr Med Assoc J. 2015;17(8):476–80.

PubMed   Google Scholar  

Beilman JP, Sowell RL, Knox M, Phillips KD. Case management at what expense? A case study of the emotional costs of case management. Nurs Case Manag. 1998;3(2):89–95.

CAS   PubMed   Google Scholar  

Xing W, Huang J, Lu Z, et al. The effect of case management nursing practice on improving the quality of life of breast cancer patients. Chin J Nurs. 2011;4(6):1053–6.

Hisashige A. The effectiveness and efficiency of disease management programs for patients with chronic diseases. Glob J Health Sci. 2012;5(2):27–48. https://doi.org/10.5539/gjhs.v5n2p27 .

Tokem Y, Argon G, Keser G. Case management in care of Turkish rheumatoid arthritis patients. Rehabil Nurs. 2011;36(5):205–13. https://doi.org/10.1002/j.2048-7940.2011.tb00197.x .

Hubbard G, Gray NM, Ayansina D, Evans JM, Kyle RG. Case management vocational rehabilitation for women with breast cancer after surgery: a feasibility study incorporating a pilot randomised controlled trial. Trials. 2013;14:175. https://doi.org/10.1186/1745-6215-14-175 .

Scherz N, Bachmann-Mettler I, Chmiel C, Senn O, Boss N, Bardheci K, Rosemann T. Case management to increase quality of life after cancer treatment: a randomized controlled trial. BMC Cancer. 2017;17(1):223. https://doi.org/10.1186/s12885-017-3213-9 .

Lamb GS. Conceptual and methodological issues in nurse case management research. ANS Adv Nurs Sci. 1992;15(2):16–24. https://doi.org/10.1097/00012272-199212000-00004 .

Morisky DE, Ang A, Krousel-Wood M, Ward HJ. Predictive validity of a medication adherence measure in an outpatient setting. J Clin Hypertens (Greenwich). 2008;10(5):348–54. https://doi.org/10.1111/j.1751-7176.2008.07572.x .

Benson JR, Dumitru D. Idiopathic granulomatous mastitis: presentation, investigation and management. Future Oncol. 2016;12(11):1381–94. https://doi.org/10.2217/fon-2015-0038 .

Ozel L, Unal A, Unal E, Kara M, Erdoğdu E, Krand O, Güneş P, Karagül H, Demiral S, Titiz MI. Granulomatous mastitis: is it an autoimmune disease? Diagnostic and therapeutic dilemmas. Surg Today. 2012;42(8):729–33. https://doi.org/10.1007/s00595-011-0046-z .

Kaviani A, Vasigh M, Omranipour R, Mahmoudzadeh H, Elahi A, Farivar L, Zand S. Idiopathic granulomatous mastitis: looking for the most effective therapy with the least side effects according to the severity of the disease in 374 patients in Iran. Breast J. 2019;25(4):672–7. https://doi.org/10.1111/tbj.13300 .

Chen L, Chungee Z, Liya S, Rong C, Jian Wu. Current status and pharmacological monitoring of long-term oral glucocorticoid patients in rheumatology department. Chin J Hosp Pharm. 2020;24(09):1020–6. https://doi.org/10.13286/j.1001-5213.2020.09.13 .

Wu F, Zhao JX, Wang TS, Shao H, Shi LW. Reliability analysis of Chinese version of MMAS-8 to measure medication adherence in patients with rheumatoid arthritis. Chin Pharm. 2018;6(02):263–8.  https://doi.org/10.6039/j.issn.1001-0408.2018.02.28 .

Lei X, Chen K, Zhu L, Song E, Su F, Li S. Treatments for idiopathic granulomatous mastitis: systematic review and meta-analysis. Breastfeed Med. 2017;12(7):415–21. https://doi.org/10.1089/bfm.2017.0030 .

Freeman CM, Xia BT, Wilson GC, Lewis JD, Khan S, Lee SJ, Lower EE, Edwards MJ, Shaughnessy EA. Idiopathic granulomatous mastitis: a diagnostic and therapeutic challenge. Am J Surg. 2017;214(4):701–6. https://doi.org/10.1016/j.amjsurg.2017.07.002 .

Keller K, Meisel C, Petzold A, Wimberger P. Granulomatöse Mastitis – möglicher diagnostischer und therapeutischer Ablauf anhand von Fallbeispielen. Senologie. 2018;15: e23.

DeHertogh DA, Rossof AH, Harris AA, Economou SG. Prednisone management of granulomatous mastitis. N Engl J Med. 1980;303(14):799–800. https://doi.org/10.1056/NEJM198010023031406 .

Akcan A, Öz AB, Dogan S, et al. Idiopathic granulomatous mastitis: comparison of wide local excision with or without corticosteroid therapy. Breast Care. 2014;9:111–5.

Tan QT, Tay SP, Gudi MA, Nadkarni NV, Lim SH, Chuwa EWL. Granulomatous mastitis and factors associated with recurrence: an 11-year single-centre study of 113 patients in Singapore. World J Surg. 2019;43(7):1737–45. https://doi.org/10.1007/s00268-019-05014-x .

Prasad S, Jaiprakash P, Dave A, Pai D. Idiopathic granulomatous mastitis: an institutional experience. Turk J Surg. 2017;33(2):100–3. https://doi.org/10.5152/turkjsurg.2017.3439 .

Agrawal A, Pabolu S. A rare case of idiopathic granulomatous mastitis in a nulliparous woman with hyperprolactinemia. Cureus. 2019;11(5): e4680. https://doi.org/10.7759/cureus.4680 .

Gupta N, Vats M, Garg M, Dahiya DS. Bilateral idiopathic granulomatous mastitis. BMJ Case Rep. 2020;13(8): e234979. https://doi.org/10.1136/bcr-2020-234979 .

Wang J, Zhang Y, Lu X, Xi C, Yu K, Gao R, Bi K. Idiopathic granulomatous mastitis with skin rupture: a retrospective cohort study of 200 patients who underwent surgical and nonsurgical treatment. J Investig Surg. 2019. https://doi.org/10.1080/08941939.2019.1696905 .

Gunduz Y, Altintoprak F, Tatli Ayhan L, Kivilcim T, Celebi F. Effect of topical steroid treatment on idiopathic granulomatous mastitis: clinical and radiologic evaluation. Breast J. 2014;20(6):586–91.

Yabanoğlu H, Çolakoğlu T, Belli S, Aytac HO, Bolat FA, Pourbagher A, et al. A comparative study of conservative versus surgical treatment protocols for 77 patients with idiopathic granulomatous mastitis. Breast J. 2015;21(4):363–9.

Kehribar DY, Duran TI, Polat AK, Ozgen M. Effectiveness of methotrexate in idiopathic granulomatous mastitis treatment. Am J Med Sci. 2020;360(5):560–5. https://doi.org/10.1016/j.amjms.2020.05.029 .

Briesacher BA, Andrade SE, Fouayzi H, Chan KA. Comparison of drug adherence rates among patients with seven different medical conditions. Pharmacotherapy. 2008;28(4):437–43. https://doi.org/10.1592/phco.28.4.437 .

Naderi SH, Bestwick JP, Wald DS. Adherence to drugs that prevent cardiovascular disease: meta-analysis on 376,162 patients. Am J Med. 2012;125(9):882–7. https://doi.org/10.1016/j.amjmed.2011.12.013 .

Gadallah MA, Boulos DN, Gebrel A, Dewedar S, Morisky DE. Assessment of rheumatoid arthritis patients’ adherence to treatment. Am J Med Sci. 2015;349(2):151–6. https://doi.org/10.1097/MAJ.0000000000000376 .

Marengo MF, Suarez-Almazor ME. Improving treatment adherence in patients with rheumatoid arthritis: what are the options? Int J Clin Rheumtol. 2015;10(5):345–56. https://doi.org/10.2217/ijr.15.39 .

Article   CAS   PubMed   PubMed Central   Google Scholar  

Johnson MG, Leal S, Plongla R, Leone PA, Gilligan PH. The brief case: recurrent granulomatous mastitis due to Corynebacterium kroppenstedtii . J Clin Microbiol. 2016;54(8):1938–41. https://doi.org/10.1128/JCM.03131-15 .

Li XQ, Yuan JP, Fu AS, Wu HL, Liu R, Liu TG, Sun SR, Chen C. New insights of Corynebacterium kroppenstedtii in granulomatous lobular mastitis based on nanopore sequencing. J Investig Surg. 2022;35(3):639–46. https://doi.org/10.1080/08941939.2021.1921082 .

Li XQ, Wu HL, Yuan JP, Liu TG, Sun SR, Chen C. Bacteria associated with granulomatous lobular mastitis and the potential for personalized therapy. J Investig Surg. 2022;35(1):164–70. https://doi.org/10.1080/08941939.2020.1833262 .

Hu X, Li S, Fu Y, Zhang N. Targeting gut microbiota as a possible therapy for mastitis. Eur J Clin Microbiol Infect Dis. 2019;38(8):1409–23. https://doi.org/10.1007/s10096-019-03549-4 .

Download references

Acknowledgements

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Science and Technology Project of The Health Planning Committee of Sichuan [Grant No. 21PJ134].

Author information

Authors and affiliations.

Department of Breast, Chengdu Women’s and Children’s Central Hospital, School of Medicine, University of Electronic Science and Technology of China, No. 1617, Riyue Avenue, Qingyang District, Chengdu, 611731, Sichuan Province, People’s Republic of China

Yuan Deng, Ying Xiong, Ping Ning, Xiao-Rong Han & Pei-Yu He

Department of Nursing, Chengdu Women’s and Children’s Central Hospital, School of Medicine, University of Electronic Science and Technology of China, No. 1617, Riyue Avenue, Qingyang District, Chengdu, 611731, Sichuan Province, People’s Republic of China

Yuan Deng, Xin Wang & Guo-Fang Tu

You can also search for this author in PubMed   Google Scholar

Contributions

PN, X-RH, and XW conceived and designed the study. YD, YX, and P-YH collected and analyzed the data. YD and YX drafted the paper. PN, XW, and G-FT read and revised the draft critically. YD and YX contributed equally to this work. All authors reviewed the manuscript. All authors read and approved the final manuscript.

Corresponding authors

Correspondence to Ping Ning or Xin Wang .

Ethics declarations

Ethics approval and consent to participate.

This study was approved by the Institution Review Board of Chengdu Women and Children’s Central Hospital Ethical approval (Grant No. B2019 (13)). All participants signed an informed consent form before data collection. All procedures performed in this study were in accordance with the ethical standards.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher's note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Deng, Y., Xiong, Y., Ning, P. et al. A case management model for patients with granulomatous mastitis: a prospective study. BMC Women's Health 22 , 143 (2022). https://doi.org/10.1186/s12905-022-01726-w

Download citation

Received : 17 January 2022

Accepted : 20 April 2022

Published : 02 May 2022

DOI : https://doi.org/10.1186/s12905-022-01726-w

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

  • Granulomatous mastitis
  • Case management
  • Medication adherence

BMC Women's Health

ISSN: 1472-6874

case study mastitis

case study mastitis

Case Study: Mastitis in Breastfeeding Woman

Connection of arm lines and mastitis in breastfeeding woman, introduction.

A 37-year-old woman presented with h/o 4 episodes of mastitis in the last one year. She is 1 year postpartum and breastfeeding. The client has h/o natural birth with min tearing and she had only one episode of mastitis after her first born. The client is doing her PhD and she has to spend time in front of the computer for her thesis. The client is an active runner. Her menstrual cycle returned 9 month postpartum.

Client Characteristics

The client does not have any medical history. The client is under stress with her dissertation otherwise she is healthy. The client stated she gets slight breast pain/clogged duct every 3 months followed by fever next day and she gets mastitis. She had to be on antibiotics for that for 4 times in the last one year. She is breastfeeding her child mainly in the evening and at night on demand. Her child goes to daycare during the day. The client really wants to avoid the pattern of mastitis and antibiotics every 3 months.

Examination Findings

Posture: Slightly rounded shoulders and slouched while seated and while breastfeeding, she mostly carries her child on the right side with hips shifted on the right side. Breathing mechanics: Decreased rib mobility, upper back tightness present ROM: Thoracic spine mobility:extension: mod loss, rotation to R/L: mod loss tightness of rib cage/thoracic spine present. Muscle strength: Both UE and LE grossly graded: 5/5 The client presented with tight superficial and deep front arm lines. The arm lines are myofascial meridians that run from the axial skeleton through the four layers of the shoulder, to the four quadrants of the arm, and four sides of the hand. The arm lines provide more mobility and require more variable lines of control and stabilization through interline links (lateral, spiral and functional). These arm lines (deep) connect the shoulders contralaterally to the pelvic girdle. (Ref: Anatomy Trains). The posture can affect the arm lines. For example, slouch posture can lead to shortening of front arm line and lengthening of back arm line which creates compensatory patterns and muscle dysfunction. The client had to do work in front of the computer- typing (using fingers) along with posture affected her arm lines. Superficial front arm line consists of palmar muscles of hands and fingers, carpal tunnel, lower arm flexors, intermuscular septum, and pectoralis major/latissimus dorsi, and medial third of clavicle, costal cartilages, lower ribs, thoracolumbar fascia, and iliac crest. The deep front arm line consists of 3rd, 4th, 5th ribs with pectoralis minor muscles, subclavius, clavipectoral fascia, coracoid process, biceps brachii, coracobrachialis, brachialis, radial tuberosity, pronator teres, supinator, radial periosteum, styloid process of radius, radial collateral ligament, scaphoid, trapezium, thenar muscles, and outside of the thumb.

To continue reading, please download the full case study.

DOWNLOAD FULL CASE STUDY

Leave a Reply Cancel reply

You must be logged in to post a comment.

case study mastitis

Insert/edit link

Enter the destination URL

Or link to existing content

case study mastitis

  • Infection Control Program
  • Environment Control Program
  • Board of Directors
  • Consultants
  • dxn1 BactFast
  • dxn1 FungiFast
  • dxn1 Virfast
  • dxn1 digitalABST
  • gSeek Onco+
  • gSeek Brain
  • GSeek Exome
  • GSeek Breast
  • GSeek ColoRectal
  • gSeek Kidney
  • gSeek Liver
  • gSeek Leukemia
  • gSeek Pancreas
  • gSeek Prostate
  • GSeek Carrier Screening
  • gSeek Transplant High Resolution
  • gSeek Transplant Low Resolution
  • GSeek Newborn Screening
  • gSeek Rare Diseases
  • gScan NIPT+
  • Clinical Diagnosis
  • Genetic Consultation
  • International
  • Testimonials

Case Study on Mastitis in Bovine Milk

A case study on microbial diversity of bovine mastitis milk.

Bovine mastitis is probably the most important disease for the dairy industry worldwide, causing economic losses due to reduced milk production, discarded milk, premature culling and excessive antibiotic use. It is also a serious bovine health issue associated with pain as well as reduced well-being of the affected animals [1]. This has become an alarming issue in certain parts of Sri Lanka due to lack of modern farming methods and proper hygienic practices. A preliminary survey on incidences of mastitis in Sri Lanka revealed an estimated loss of Rs. 4.3 million occurring annually due to this condition [2]. Bovine mastitis exists in unnoticeable subclinical form for months, spreading from one location to another, with high tendency of being nonresponsive to therapy. Chronically infected cows act as carriers and they impose a severe economic burden [3].

Bovine mastitis has a complex aetiology, being caused by a variety of bacteria and also by chemical and physiological factors. Streptococcus agalatiae is found to be the commonest agent causing chronic contagious mastitis. Staphylococcus aureus , S. dysgalatiae,S.uberis, Mycoplasma spp, Esherichia coli , environmental streptococci spp., Pseudomonas spp , yeast, fungi and alga such as Prototheca   also cause disease implications [4]. Identification of bacteria causing this intramammary infection is the basis for controlling mastitis and targeting antimicrobial therapy. In the identification procedures, bacterial culture-based methods have long served as the gold standard for mastitis testing. However, these conventional tests are time consuming, with a routine turnaround time of 7 days. It also requires operator expertise, leading to differences in the results between different testing laboratories. Additionally, 25%-40% of milk samples from clinical and subclinical mastitis show no bacterial growth in conventional culturing. To overcome drawbacks of culture based techniques, real-time PCR was used for disease identification and pathogen classification with the aid of commercially available kits [6]. Although the technique could eliminate the shortcomings, disease detection using this technique required prior knowledge on the causal organism. Due to the complex aetiology of mastitis, however,prior knowledge on exact causal organism is rare. In addition, interpretation of results depends on a fluorescent labeling mechanism, which is relatively costlier compared to culture based techniques, in turn limiting the number of organisms which could be checked during a single run. Apart from real-time PCR, multiplex PCR (mPCR), denaturing gradient gel electrophoresis (DGGE) PCR, and PCR single-strand conformation polymorphism (SSCP) are now being used to identify bacterial DNA in milk samples. But these techniques hardly facilitate testing of bulk milk samples, which is a major drawback in large scale industrial testing.

Fig-  Phylogram of Streptococcus spp. and related bacteria isolated from bovine IMI associated with chronic mastitis[7]

case study mastitis

Sequencing and analysis of hypervariable regions within the 16S rRNA gene can provide relatively rapid and cost-effective, large scale methods for assessing bacterial diversity and abundance and is a definite advantage for pathogen discovery and identification. This technique uses raw milk as a starting material, does not require bacterial culturing, takes only 10 hours to complete the run, and enables a dramatic increase in throughput via parallel in depth analysis of many samples with lower costs. The analytical specificity and sensitivity of the test is unmatched and the test organisms can be classified up to species level while identifying their intragenic variations as well as relative abundances. Furthermore, the correlation of these bacteria to bovine chronic mastitis and their phylogeny can be investigated. Thus, 16s rRNA gene sequencing can be very efficient as a massively parallel technique that allows large scale testing of industrial raw milk samples. Thus, dairy processors can look forward to more detailed, cheaper, rapid and accurate identification of pathogens residing in their milk samples.

To summarize, 16s rRNA Sequencing has following advantages compared to other techniques-

case study mastitis

References-

  • Oikonomou, Georgios, et al. “Microbial diversity of bovine mastitic milk as described by pyrosequencing of metagenomic 16s rDNA.”  PloS one 10 (2012): e47671.
  • Wickramasuriya, U. G. J. S. “EVALUATION OF A MASTITIS CONTROL PROGRAMME ADOPTED IN SMALL DAIRIES IN THE DISTRICT OF COLOMBO.” (1985).
  • Thilakarathne D.S., Abeynayaken P et al “Bacterial Isolates and In Vitro Biogram of Milk Collected from Cows with Chronic Mastitis in the Central Province of Sri Lanka” Proceedings of the Peradeniya University Research Sessions, Sri Lanka, Vol. 16, 24th November 2011.
  • Ravindran,V. Sriskandarajah, N. Rajamahendran, R.. 2010.  Diseases and parasites of domesticated animals in Sri Lanka  . [ONLINE] Available at:  http://dl.nsf.ac.lk/handle/1/5159 . [Accessed 25 September 13].
  • ansci.illinois.edu. 2013.  Mastitis Pathogens . [online] Available at: http://classes.ansci.illinois.edu/ansc438/mastitis/pathogens.html [Accessed: 22 Nov 2013].
  • Koskinen, M. T., et al. “Field comparison of real-time polymerase chain reaction and bacterial culture for identification of bovine mastitis bacteria.” Journal of dairy science 12 (2010): 5707-5715.
  • Wyder, Anna Barbara, et al. “Streptococcus spp. and related bacteria: Their identification and their pathogenic potential for chronic mastitis–A molecular approach.”  Research in veterinary science 3 (2011): 349-357.
  • Janda, J. Michael, and Sharon L. Abbott. “Bacterial identification for publication: when is enough enough?.”  Journal of clinical microbiology 6 (2002): 1887-1891.

YOU MAY ALSO LIKE

BMC Infectious Diseases publishes Credence RID, Bactfast & Fungifast

BMC Infectious Diseases publishes Credence RID, Bactfast & Fungifast

Leave a reply cancel reply.

Your email address will not be published. Required fields are marked *

Sample post for Internal

Eye live interview dr. vaz santosh gnanam – ceo / director – credence genomics.

  • Adt Security Contracts

Your inquiry has been received.

Close

A case-control study of mastitis: nasal carriage of Staphylococcus aureus

Affiliation.

  • 1 Mother & Child Health Research, La Trobe University, Melbourne, Australia. [email protected]
  • PMID: 17032458
  • PMCID: PMC1630426
  • DOI: 10.1186/1471-2296-7-57

Background: Mastitis is a common problem for breastfeeding women. Researchers have called for an investigation into the possible role of maternal nasal carriage of S. aureus in the causation of mastitis in breastfeeding women.

Methods: The aim of the study was to investigate the role of maternal S. aureus nasal carriage in mastitis. Other factors such as infant nasal S. aureus carriage, nipple damage, maternal fatigue and oversupply of milk were also investigated. A case-control design was used. Women with mastitis (cases, n = 100) were recruited from two maternity hospitals in Melbourne, Australia (emergency departments, breastfeeding clinics and postnatal wards). Breastfeeding women without mastitis (controls, n = 99) were recruited from maternal and child health (community) centres and the rooms of a private obstetrician. Women completed a questionnaire and nasal specimens were collected from mother and baby and placed in charcoal transport medium. Women also collected a small sample of milk in a sterile jar.

Results: There was no difference between nasal carriage of S. aureus in breastfeeding women with mastitis (42/98, 43%) and control women (45/98, 46%). However, significantly more infants of mothers with mastitis were nasal carriers of S. aureus (72/88, 82%) than controls (52/93, 56%). The association was strong (adjusted OR 3.23, 95%CI 1.30, 8.27) after adjustment for the following confounding factors: income, private health insurance, difficulty with breastfeeding, nipple damage and tight bra. There was also a strong association between nipple damage and mastitis (adjusted OR 9.34, 95%CI 2.99, 29.20).

Conclusion: We found no association between maternal nasal carriage of S. aureus and mastitis, but nasal carriage in the infant was associated with breast infections. As in other studies of mastitis, we found a strong association between nipple damage and mastitis. Prevention of nipple damage is likely to reduce the incidence of infectious mastitis. Mothers need good advice about optimal attachment of the baby to the breast and access to skilled help in the early postpartum days and weeks.

Publication types

  • Research Support, Non-U.S. Gov't
  • Breast Feeding / adverse effects*
  • Carrier State / microbiology
  • Case-Control Studies
  • Community Health Centers
  • Hospitals, Maternity
  • Infant, Newborn
  • Mastitis / diagnosis
  • Mastitis / microbiology*
  • Nasal Mucosa / microbiology*
  • Nipples / microbiology
  • Nipples / pathology
  • Risk Factors
  • Staphylococcal Infections / diagnosis
  • Staphylococcal Infections / microbiology
  • Staphylococcal Infections / transmission*
  • Staphylococcus aureus / isolation & purification*

Mastitis Case Study: A 36 yo post-partum patient comes to the...

Mastitis Case Study: A 36 yo post-partum patient comes to the office for her 2 week follow-up for a Cesearean Section birth. She is doing well other than her complaint of a painful area in her right breast. Upon exam of the right breast the examiner identifies a 3 cm area that is red, tender and warm to touch on the right lateral aspect of the nipple area. The patient states that she has been having difficulty breastfeeding due to the discomfort. She has had a temp of 100F for the last 2-3 days. PMH: unremarkable. Prenatal history: S/P Repeat Cesearean Section 2 weeks ago due to previous C-section. NKA. No meds.  Assessment: Mastitis of right breast. Based on this case study: 

  • Provide 3 differential diagnoses along with rationale and ICD codes.
  • What additional assessment/information would you anticipate?
  • What are the potential complications of mastitis?
  • What treatment plan would you anticipate?
  • What is the plan of care if this mother wants to continue to breastfeed?
  • What educational information would you want to discuss related to the prevention of mastitis?
  • If this patient is prescribed antibiotics, would breastfeeding be contraindicated?

Answer & Explanation

ICD Codes, Differential Diagnosis, and Rationale for Their Use 1. Mastitis Mastitis, also known as mastitis, is an infection of the breast tissue that can be caused by a fungal or bacterial infection. In addition to a fever, the affected area may often exhibit symptoms such as redness, discomfort, swelling, and warmth. In other cases, the temperature may be the only symptom. The ICD diagnosis for mastitis is N61.1, and the symptoms that this patient is exhibiting are consistent with having mastitis. 2. Abscess: An abscess is a collection of pus that is caused by an infection. It is commonly characterized in the affected area by localized discomfort, redness, warmth, and edema. Other symptoms may also be present. The ICD code for abscess is L02, thus it is probable that the patient has an abscess in her right breast.

3. Inflammatory Breast Cancer: Inflammatory breast cancer is a particularly aggressive form of breast cancer that, as a result of its presentation, frequently results in an incorrect initial diagnosis. The affected region will often exhibit signs of inflammation, including redness, swelling, and warmth. It is conceivable that the patient has inflammatory breast cancer, which has the ICD code of C50.8. The code for inflammatory breast cancer appears in the International Classification of Diseases.

In-Depth Analyses and Detailed Information It is essential to gather further information so that a correct diagnosis can be made for the patient and a suitable treatment plan can be devised. It is important to ask the patient about her medical history, including whether or not she has ever breastfed, whether or not she has ever experienced any problems linked to nursing, any recent changes, or any other concerns she may have. It is also essential to gather a complete history of the patient's symptoms, including the length of time they have been present and how severe they have been. It is important to do a thorough physical examination of the affected region in order to look for any further indications or symptoms. In addition to it, there should be tests carried out in the laboratory, such as a complete blood count or a mammography.

Possible problems Associated with Mastitis If mastitis goes untreated, it can result in a number of potentially life-threatening problems, including sepsis, a systemic infection, and an abscess. In addition, mastitis can result in scarring of the breast tissue, which can lead to a reduction in milk supply, difficulty breastfeeding, and a decline in the quality of breastmilk. These symptoms can all be caused by breastfeeding difficulties.

Strategy for Treatment Antibiotics and other forms of supportive care are often used in conjunction with one another as part of the treatment plan for mastitis. Antibiotics are often provided to treat the underlying infection, and supportive treatment, such as frequent breastfeeding, rest, and warm compresses, should be recommended to alleviate pain, inflammation, and discomfort. Antibiotics are typically prescribed to treat the underlying infection. In addition, the patient needs to be urged to refrain from using any lotions or creams on the affected area and to avoid wearing clothes that is too restrictive.

a care plan in the event that the mother want to maintain her breastfeeding relationship If the patient intends to breastfeed for an extended period of time, she should be instructed to express milk as frequently as is practical. This will assist in lowering the likelihood of infection while also maintaining clear milk ducts. In addition to this, the patient should be instructed to continue taking the antibiotics that were prescribed to them and to apply warm compresses to their affected areas in order to alleviate any discomfort. In addition to this, the patient should be cautioned against using any lotions or creams on the affected region as well as against wearing clothing that is too tight.

Information for the Purpose of Education Regarding the Preventing of Mastitis It is important to teach the patient how to avoid getting mastitis in the future. This includes avoiding clothes that is too tight, wearing a bra that provides support, and avoiding applying any kind of lotions or creams to the area that is afflicted. In addition to this, the patient ought to be advised to nurse their child using both breasts and to observe appropriate hygienic practices, such as washing their hands before and after doing so. In addition, it is important to advise the patient to take numerous breaks and to rest in between each feeding session.

If the doctor prescribed antibiotics, would it be dangerous to continue breastfeeding? In most cases, breastfeeding moms are not advised against taking antibiotics because doing so is not considered to be harmful to the baby. However, it is essential to discuss any potential hazards connected with taking the medicine while breastfeeding with the patient's primary care physician prior to beginning treatment with the medication. Additionally, it is essential to check that the patient is receiving the correct dosage of the prescription and that the mother can continue to breastfeed while taking the antibiotics. Additionally, it is important that the patient be instructed to express milk as regularly as possible in order to lessen the likelihood of infection and maintain clear milk ducts.

References 1. Mastitis: Symptoms, Causes, and Treatment. (n.d.). Retrieved from https://www.webmd.com/women/guide/mastitis#1  2. Abscess: Symptoms, Causes, Diagnosis, and Treatment. (n.d.). Retrieved from https://www.webmd.com/skin-problems-and-treatments/guide/abscess#1 3. Inflammatory Breast Cancer: Symptoms, Causes, Diagnosis, and Treatment. (n.d.). Retrieved from https://www.webmd.com/breast-cancer/inflammatory-breast-cancer#1  4. Brown, S. (2019, December 4). Mastitis: Causes, Symptoms, Treatment, and Prevention. Retrieved from https://www.healthline.com/health/mastitis#prevention  5. Mastitis and Breastfeeding. (2019, October 18). Retrieved from https://www.cdc.gov/breastfeeding/breastfeeding-special-circumstances/maternal-infections/mastitis.html  6. Breastfeeding: Answering Common Questions About Breastfeeding and Medication. (n.d.). Retrieved from https://www.cdc.gov/breastfeeding/breastfeeding-special-circumstances/medication/medication-and-breastfeeding.html

Related Q&A

  • Q : A 34-year-old Caucasian woman presents to her PCP with a 3-day history of pain in her right nipple. She is married, th... Answered 87d ago
  • Q Mastitis in female Briefly discuss the condition/disorder. Describe the symptoms and physical exam findings associated w... Answered over 90d ago
  • Q Analyse which strategies are best for creating long term value in the modern firm. Would your answer change if the organ... Answered over 90d ago
  • Q please see the attachments. there are no other files provided.  . 1 #include&lt;iostream&gt; 2 #include&lt;fstream&gt; 3... Answered over 90d ago
  • Q Question 10 1 pts  Which of the following is NOT a documentation requirement when procuring goods from international mar... Answered 80d ago
  • Q A scientist studying babies born prematurely would like to obtain an estimate for the mean birth weight, , of babies bor... Answered 87d ago
  • Q Assessment 2 2,000- word written essay. Students will be required to prepare for, research and produce a written 1,000- ... Answered over 90d ago
  • Q You run a nail salon. Fixed monthly cost is $5,939.00 for rent and utilities, $5,767.00 is spent in salaries and $1,694.... Answered over 90d ago
  • Q You are the Revenue Cycle Manager for Joplin Hospice.  You have only been in this position for 4 months.  One of the thi... Answered over 90d ago
  • Q  . Meltzer (1971). After a block of practice rotated comparison stimulus (0 or no rotation). Then, students will be test... Answered over 90d ago
  • Q Please help with these. 1' ms 3 8 E SRAS AD 0 Real GDP The economy shown in the graph would benefit from which of the fol... Answered over 90d ago
  • Q Pricing Refrigerators Best Buy, a nationwide retailer of electronics, computers, and appliances, sells several brands of... Answered over 90d ago
  • Q watch this video: Classroom Mgmt. - Week 1 - Day 3   - https://youtu.be/geLvLd3uosk   *  would you summarize Day 3? * Wh... Answered 46d ago
  • Q Adam, a recently hired bookkeeper at your company, is worried about his prospects in the Accounting profession. You hear... Answered over 90d ago
  • Q Describe any trends shown in the graph.. Women's Marathon Record Progression 210 200 190 180 170 Winning Time (min) 160 ... Answered over 90d ago
  • Q 1. summarize the origins of law enforcement in the Canada . 2. . Describe Toronto police its organizational structure, r... Answered 30d ago

U.S. flag

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

  • Publications
  • Account settings
  • Advanced Search
  • Journal List
  • BMC Womens Health

Logo of bmcwh

A case management model for patients with granulomatous mastitis: a prospective study

1 Department of Breast, Chengdu Women’s and Children’s Central Hospital, School of Medicine, University of Electronic Science and Technology of China, No. 1617, Riyue Avenue, Qingyang District, Chengdu, 611731 Sichuan Province People’s Republic of China

2 Department of Nursing, Chengdu Women’s and Children’s Central Hospital, School of Medicine, University of Electronic Science and Technology of China, No. 1617, Riyue Avenue, Qingyang District, Chengdu, 611731 Sichuan Province People’s Republic of China

Xiao-Rong Han

Guo-fang tu, associated data.

The datasets generated and/or analyzed during the current study are not publicly available due to restrictions related to confidentiality i.e., they contain information that could compromise the privacy of research participants, but are available from the corresponding author on reasonable request.

Granulomatous mastitis (GM) is a chronic inflammatory mastitis disease that requires long-term treatment and has a high recurrence rate. Case management has been proven to be an effective mechanism in assisting patients with chronic illness to receive regular and targeted disease monitoring and health care service. The aim of this study was to investigate the application of a hospital-to-community model of case management for granulomatous mastitis and explore the related factors associated with its recurrence.

This was a prospective study on patients with granulomatous mastitis based on a case management model. Data on demographic, clinical and laboratory information, treatment methods, follow-up time, and recurrence were collected and analyzed. The eight-item Morisky Medication Adherence Scale (MMAS-8) was used to investigate patients' adherence to medications. Logistic regression models were built for analysis of risk factors for the recurrence of granulomatous mastitis.

By October 2021, a total of 152 female patients with a mean age of 32 years had undergone the entire case management process. The mean total course of case management was 24.54 (range 15–45) months. Almost all the patients received medication treatment, except for one pregnant patient who received observation therapy, and approximately 53.9% of the patients received medication and surgery. The overall recurrence rate was 11.2%, and “high” medication adherence (RR = 0.428, 95% CI 0.224–0.867, P  = 0.015) was significantly associated with a lower rate of recurrence, while the rate of recurrence with a surgical procedure + medication was higher than that with medication alone (RR = 4.128, 95% CI 1.026–16.610, P  = 0.046).

A case management model for patients with granulomatous mastitis was applied to effectively monitor changes in the disease and to identify factors associated with disease recurrence. “Low” medication adherence was a significant risk factor for the recurrence of granulomatous mastitis. Patients treated with medication and surgery were more likely to experience recurrence than those treated with medication alone. The optimal treatment approach should be planned for granulomatous mastitis patients, and patient medication adherence should be of concern to medical staff.

Granulomatous mastitis (GM) was first reported as a chronic inflammatory disease of the breast by Kessler and Wolloch in 1972 [ 1 ], and accounts for approximately 1.8% of benign breast diseases [ 2 ]. The main clinical presentation is a palpable, painful breast lump with concomitant skin erythema, nipple retraction, sinus tract formation, cellulitis changes, and axillary adenopathy formation [ 3 – 5 ], and in severe cases, there are usually multiple coexisting focal abscesses with skin inflammation and ulceration [ 5 ]. According to the severity of the disease, GM is clinically classified into mass, abscess, and refractory types [ 6 ]. Patients often endure a long disease course, as well as changes in breast appearance caused by the disease, which has serious physical and psychological effects on patients [ 7 ]. With only 2.4 per 100,00 incidences reported by the Centers for Disease Control and Prevention in 2009, most countries have not conducted large epidemiological surveys for GM due to the rarity of the disease [ 8 ]. To date, the etiology of GM is unknown and may be associated with a history of pregnancy, autoimmune disease, breast trauma, hyperprolactinemia, and infection [ 7 , 9 ]. The disease progresses rapidly with a recurrent or prolonged natural course, which has a high recurrence rate of 5%-50%, and is commonly seen in young women with a history of breastfeeding and childbirth [ 3 , 10 – 12 ]. As recently reported, there are racial differences in this disease, and the incidence of GM in Middle Eastern countries (Egypt, Turkey, Iran) and Spain is higher than that in Western countries (UK, USA, New Zealand) [ 13 – 15 ]. A large number of cases of GM have been described, mainly from Asian and Mediterranean countries, such as China, Iran, and Turkey [ 16 , 17 ]. However, there is no consensus on the management of GM and no gold standard regarding the diagnosis and treatment of the disease [ 4 ]. Currently, the main treatment include observation, medication therapy (steroids, antibiotics, methotrexate (MTX), and anti-molecular bacilli) and/or operative interventions (abscess incision and drainage, simple mass excision, enlarged mammary mass excision, etc.) [ 15 , 18 ], and medication therapy is the most commonly used treatment. The toxic side effects of long-term medication use have a significant impact on patients' quality of life, resulting in poor compliance with drug use, therefore, timely observation of medication use and changes in the breasts is essential to achieve good recovery rates for GM patients [ 11 , 18 – 20 ].

Recently, one approach to managing care that has gained wide popularity is case management [ 21 ], which promote access to provide patients with regular and targeted disease monitoring and health guidance through follow-up visits and WeChat consultations in China (WeChat is a mobile chat software by the Chinese company Tencent, in which patients can quickly consult with medical staff by sending voice messages, videos, pictures and texts over the internet quickly) [ 22 ]. Nurse specialists are responsible for the overall coordination, management, and continuity of care for a specific treatment or intervention to meet the health needs of an individual, reduce health care costs and improve the quality of service [ 23 , 24 ]. Currently, it is known that case management is widely applied for patients with breast disease, especially breast cancer [ 25 , 26 ], but it is rarely to applied for GM patients. Based on the characteristics of the disease, which is mostly treated and followed up in outpatients, a tailored model should be developed that it enables health providers monitor the condition changes of GM patients from outpatient to community to inpatient settings. A hospital-to-community model of case management, which allows cases managers to track and manage the treatment of GM patients from hospital to community settings, was described by Lamb in 1992, and includes the following five basic activities of case management: (1) assessment, (2) planning, (3) linking, (4) monitoring, and (5) advocacy [ 27 ]. Since January 2018, a tailored model for GM based on a hospital-to-community model, which can provide patients with full management and seamless health care services, has been explored and practiced in Chengdu Women's and Children's Central Hospital.

To better observe the development of this disease with treatment and identify some of the factors associated with its recurrence, we used a hospital-to-community-based model of case management to monitor the condition changes of GM patients. Prospective studies can provide more effective strategies and optimal approaches to prevent the recurrence of disease.

Materials and methods

Study design and participants.

A prospective study on patients with granulomatous mastitis based on the case management model was undertaken between January 2018 and November 2020 in the Breast Unit of Chengdu Women’s and Children’s Central Hospital. According to the characteristics of the disease, the whole case management process, presented in Fig.  1 , was divided into four key stages, including the diagnostic, conservative, perioperative, and follow-up periods. The entire process was led by case managers and tailored for patients, including the evaluation, planning, integration, implementation, and evaluation of treatment plans. Participants were followed up through the whole process. The case closure time was defined as the time when a patient was free of relapse during the 1-year follow-up period after the discontinuation of medication or surgery.

An external file that holds a picture, illustration, etc.
Object name is 12905_2022_1726_Fig1_HTML.jpg

the algorithm for the case management of granulomatous mastitis

In the diagnostic stage, the case managers mainly based their decisions on clinical symptoms, regardless of whether a register of the initial medical history was created including age, pregnancy history, disease history, onset time, onset trigger, and contact phone number. A patient’s diagnosis of granulomatous mastitis was confirmed by the results of a pathological examination by core needle biopsy, and then a case management file was established. In the conservative treatment stage, case managers mainly performed the following: (1) followed up and recorded the results of ultrasounds, abnormal laboratory tests and breast signs, and explained the precautions and methods of medication administration according to a doctor's prescription; (2) surveyed GM patients for medication adherence at 2 months of drug use by the eight-item Morisky Medication Adherence Scale (MMAS-8) [ 28 ]; (3) distributed notes of disease considerations related to diet, sleep, behaviors, etc., as shown in Table ​ Table1 1 [ 6 , 29 , 30 ]; and (4) established a contact platform for GM patients to understand and observe the changes in their breasts during treatment, while being given psychological support and guidance at home. In the perioperative and follow-up periods, the case managers recorded the patients' surgery, medication, follow-up time and recurrence information.

Notes of disease considerations

In this study, qualifications for case managers were as follows: (1) nurses with bachelor's degree or above; (2) nurses with an intermediate title or above; (3) nurses with 5 years of experience or more in the breast department; (4) nurses who had received the training, which included the case management process, communication and health promotion skills; (5) nurses who were required to rotate through the breast clinic, ultrasound and pathology department, wound care unit and operating room, and (6) nurses who had passed the hospital examination for case management. All patients who received case management were eligible for inclusion if they were older than 18 years, had clinical breast symptoms, and had a confirmed diagnosis by core needle biopsy. Patients were ineligible if they had other complications of the breast and had been treated at other institutions. The study was approved by the Ethics Committee of Chengdu Women's and Children's Central Hospital (No. B2019 (13)). All participants signed an informed consent form.

Case definition

Histopathological examination is a necessary and gold-standard method for the diagnosis of granulomatous mastitis [ 31 ], so a definitive diagnosis of GM was largely accomplished with core needle biopsy in this study. The disease may be locally invasive with a risk of recurrence, and recurrence rates of 5 to 50% have been observed by various studies in recent years [ 10 – 12 ]. The following definition of recurrence was used in this study: the detection of new lesion (s) within the range of the primary location or any other part of the ipsilateral breast 1 month following the termination of therapy.

Medication adherence was measured using the eight-item Morisky Medication Adherence Scale (MMAS-8) [ 28 ], which was translated into a Chinese scale by Lin Chen et al. [ 32 ]; this scale has high reliability and validity and has been widely used in studies of various chronic diseases in China [ 32 , 33 ]. Three levels of adherence were considered based on the following scores: 0 to < 6 (low); 6 to < 8 (medium); and 8 (high). In a meta-analysis by Lei et al. [ 34 ], oral drug therapy was an effective treatment modality or GM patients in receiving both surgical and conservative treatment. According to the relevant literature, steroids are the most prominent drugs for GM, which usually lasts from 3 to 12 months, with a minimum of 2 months [ 35 – 38 ]. To survey as many patients as possible, we chose to conduct a survey of medication adherence at 2 months of medication use.

Statistical analysis

The statistical software package SPSS for Windows, version 19.0 (SPSS Inc., Chicago, IL) was used for statistical analysis. Clinical characteristics were described using the mean ± standard deviation, the mean (range) or numbers (and percentages) as appropriate. Continuous variables were compared between patients with and without recurrence using one-way ANOVA, while categorical variables were compared using the Chi-square test and Fisher's exact tests. Logistic regression models were built for the analysis of risk factors for the recurrence of GM.

Patient characteristics

In this study, 204 symptomatic patients with granulomatous mastitis were initially included in the diagnostic stage between January 2018 and November 2020. However, 4 patients were diagnosed with breast cancer, 8 dropped out, and 40 were still undergoing case management. Ultimately, 152 patients had completed case management by September 2021. Table ​ Table2 2 shows that the mean age of the patients was 32 years (range 22–48). It was observed that 71 (46.7%) patients had normal BMI, while 64 (47,4%) patients had a BMI higher than 25, and were considered overweight or obese. It was detected that the period in which GM was most frequently seen was the first 2–5 years after birth, with 94 patients (61.8%), followed by 30 patients (19.7%) diagnosed 0–2 years after birth (4 patients were breastfeeding), and 15 patients (9.9%) diagnosed during pregnancy. Accompanying diseases were found in only 28 (18.5%) patients, such as diabetes mellitus, thyroid disease, psychoses, hypertension, and hyperprolactinemia, accounting for the highest percentage of 13.8% of all comorbidities.

Demographic and clinical characteristics of 152 patients

On physical examination, the most common finding was a palpable mass with pain (98.7%); 38.8% of the patients had a breast abscess, 75% suffered from skin lesions, and approximately 5% had fistulas and erythema nodosum (Table ​ (Table2). 2 ). Based on clinical symptoms, the disease was typed as the mass (74, 48.7%), abscess (66, 43.4%), and refractory types (12, 7.9%). Unilateral involvement was observed the most in 140 (92.1%) patients. In this study, 30.96% of the patients reported that they had bad behaviors a week before disease onset, including breast trauma (8.6%), excitant food (14.47%), and staying up all night (7.89%).

Patient treatments

Table ​ Table3 3 shows the different treatments that were administered. Of the 152 patients, only 1 (0.7%) recovered under observation without treatment, 82 (53.9%) recovered with medication and surgery, and 69 (45.4%) recovered with medical treatment alone. In the courses of medications, 65 (42.8%)patients chose systemic steroids alone, 21 (13.7%) patients chose tubercle bacillus drugs alone, and 65 (42.8%) patients required a combination or change of the drug regimen due to ineffective treatment or drug side effects including erythema nodosum (5.3%), skin rash (5.3%), abnormal index of liver function (7.2%), abnormal uric acid (2.0%) and edema on the lips and face (0.7%).

Treatments of patients

Patient follow-up visits

The mean follow-up time was 25.55 months (range 15–45) for the patients treated with medication and surgery, while it was 23.83 months (range 17–36) for the patients treated with medication alone. There was no statistically significant difference between the groups ( p  = 0.570). The recurrence rate in the series was determined to be as 11.2% with 17 patients experiencing recurrence. At 2 months of initial medication use, the medication adherence outcome of the GM patients was “high” for 59 patients (39%), “medium” for 70 patients (46.4%), and “low” for 22 patients (14.6%), as shown in Table ​ Table4 4 .

Follow-up visit of patients

Factors associated with recurrence

All statistically significant variables ( P < 0.05) related to BMI, treatments, medication use and medication adherence (Table ​ (Table5) 5 ) were included in the multivariable logistic regression model. The results of the multivariable analysis are shown in Table ​ Table6. 6 . Surgical procedure and drug treatment (RR = 4.128, 95% CI 1.026–16.610, P  = 0.046) were independently associated with an increased recurrence risk of granulomatous mastitis. In contrast, “high” medication adherence (RR = 0.428, 95% CI 0.224–0.867, P  = 0.015) was associated with decreased recurrence risk.

The characteristics in GM patients with and without recurrence

Risk factors for GM recurrence by multivariate analysis

Discussion and conclusion

This is the first study to report a case management model applied for GM patients. Although GM is a benign disease, its recurrence, one of the main challenges in the management of patients with the disease, has been reported to occur in 5%-50% of patients [ 10 – 12 ]. In our study, the recurrence rate of 11.2% is low in this range. Seventeen patients experienced recurrence, including ten with new lesions in the ipsilateral breast and seven with new lesions in the contralateral breast.

In recent years, the prevalence of granulomatous mastitis has been rapidly increasing, and the most affected patients are women of childbearing age [ 39 ]. In two studies, Freeman et al. reported that up to 86% of GM patients had a history of pregnancy in the past 5 years [ 38 ]. Prasad et al. reported that 73 patients with GM had a mean age of approximately 33 years and a history of childbirth 4.6 years before mastitis on average [ 40 ]. In our study, which had similar characteristics to previously reported studies, the median age of the patients was 32 years (range 22–48), 119 patients had a history of childbirth within the last 5 years, 15 patients had concurrent pregnancy, and 4 patients were currently breastfeeding. These findings indicated that hormones play an important role and may be related to the secretion theory, which has an important place in the pathophysiology of GM [ 12 ]. It has been postulated that GM results from a localized autoimmune response to the retained or extra vacated fat- or protein-rich secretions in the breast ducts in women of childbearing age due to previous hyperprolactinemia [ 41 ]. Therefore, the breast care for women of childbearing age deserves our attention.

GM patients mostly have mass and pain symptoms, and skin lesions and abscesses can be observed in mass localization. Findings such as fistula, erythema nodosum, and nipple or skin retraction can also be observed [ 1 , 2 , 35 ]. In many studies, the most common reported complaint at the time of the initial visit was a unilateral painful breast mass [ 35 , 42 ]. Similarly, 98.7% of the patients had mass and pain complaints, and 92.1% of the patients presented with a unilaterally affected breast. The case managers made initial judgments and provided tentative guidance based on clinical presentations. At the initial visit, there were mass (74, 48.7%), abscess (66, 43.4%), and refractory types (12, 7.9%), which were not associated with recurrence in the later stages ( P  = 0.2). As the disease progressed, 10 mass type cases were actually abscess type cases, and 4 abscess type cases were actually refractory type cases. An important consideration for case managers is the care of the affected breast (shown in Fig.  2 and Fig.  3 ). Wound care should consist of managing drainage from fistulae with gauze and other nonadherent dressings. Tape should be avoided due to further abrasion and irritation of the skin [ 43 ]. Meanwhile, if a patient has a superficial abscess, a case manager should percutaneously perform puncture aspiration, and determine how deep the abscess is, while a mammographer, assisted by ultrasound guidance, performs puncture drainage, to create a path for the drainage of secretions and reduction of pressure in the inflamed area due to the accumulation of inflammatory fluid.

An external file that holds a picture, illustration, etc.
Object name is 12905_2022_1726_Fig2_HTML.jpg

The effect of medical and surgical treatment in the case management. The underlined part of the figure shows the scope of the lesion located by ultrasound. a Before the treatment. b After the steroids treatment for 4 months and before surgical treatment. c Before stopping the steroids treatment and after right breast lesion excision for 1.5 months

An external file that holds a picture, illustration, etc.
Object name is 12905_2022_1726_Fig3_HTML.jpg

The effect of medical treatment in the case management. a Before the medical treatment and wound care. b After the tubercle bacillus drug and wound care for 14 months

Comparing the most recent publications on GM to older studies, there is no new information on this benign breast disease. Therefore, the best management of this disease is still unclear [ 11 , 12 ]. The usual treatment for GM is close observation, medical treatment, surgical management, or a combination of medication and surgery [ 3 , 15 , 44 ]. In the present study, only 1 (0.7%) patient recovered under observation, 82 (53.9%) recovered with medication and surgery (as shown in Fig.  2 ), and 69 (45.4%) recovered with medication alone (as shown in Fig.  3 ). Multivariate analysis revealed that medication and surgery was significantly associated with recurrence (RR = 4.128, 95% CI [1.026–16.610], P  = 0.0046) (Table ​ (Table6). 6 ). Regarding the cause of recurrence, previous studies have ascribed the incompleteness of excision to the failure of surgical treatment, or inconsistent follow-up times. In this study, case managers assessed changes in the size of the breast mass and the proportion of the mass to the breast size and considered whether the patients could undergo surgical excision with minimal impact on the aesthetics of the breast. Breast lesion excision by minimally invasive surgery or open surgery was applied, which may have a risk of incomplete surgical excision. Akcan et al. and Yabanoğlu et al. reported that complete excision of the breast lesion or wide excision with or without medication achieved low recurrence rates [ 38 , 45 ]; however, it is possible to cause damage to the breast due to the excessive removal of tissues. Therefore, the biggest problem with surgical treatment is the contradiction between the surgical effect and the postoperative aesthetic effect. Whether the surgical procedure that is chosen which increases the recurrence rate of GM requires further investigation.

Our study demonstrated that medical treatment is the most prevalent treatment, regardless of whether it is coupled with surgical treatment. Drug therapies have numerous side effects, such as Cushion's syndrome, skin rash, abnormal liver enzymes and abnormal uric acid and [ 46 ]. In our study, 8 (5.3%) patients suffered from skin rash, 11 (7.2%) had abnormal liver enzymes, 3 (2.0%) had abnormal uric acid, and 1 (0.7%) had edema on the lips and face (as shown in Table ​ Table3). 3 ). In this stage, case managers served as a treatment team by linking physicians, pharmacists, dermatologists, obstetricians, and general practitioners. They immediately communicated with the multidisciplinary team, and then guided patients regarding their medications, and finally, most of the side effects disappeared within 1 week.

To the best of our knowledge, there are no studies investigating medication adherence in GM patients. In our study, it shown that the MMAS-8 was completed by 154 patients, with 39% who had high adherence, 46.4% who had medium adherence, and 14.6% who had low adherence. As a result of case manager guidance, the “low” medication adherence rate of GM patients was much lower than that of 30% and 50% of reported for adults with chronic disease [ 47 , 48 ]. Furthermore, “high” medication adherence (RR = 0.428, 95% CI 0.224–0.867, P  = 0.015) at 2 months after initial medication use was significantly associated with a lower rate of recurrence in multivariate analysis. At the initial stage, the case managers paid more attention to the changes in the patients’ breast symptoms than to patient medication adherence, and the guidance and supervision of medical staff to patient medication need improvement. Currently, several reports have demonstrated the importance of regular visits to a physician, adequate patient contact time in clinical practice, and patient education to improve medication adherence to treatment [ 49 , 50 ].

Recent evidence indicates that the occurrence and recurrence of GM is associated with the Corynebacterium species, especially Corynebacterium kroppenstedtii [ 39 , 51 ]. In our study, samples of C. kroppenstedtii were obtained by ultrasound guidance for the puncture or biopsy of breast abscesses or hypoechoic masses. Breast pus or tissues were used for bacterial culture, and the positive rate of C. kroppenstedti was only 23.69% (36/152). In different studies, the positive rate of C. kroppenstedtii varies considerably, mainly due to the detection techniques. Li et al. [ 52 ] reported that nanopore sequencing showed accurate C. kroppenstedti detection over the culture method in GM patients. Therefore, the need to improve detection techniques for the Corynebacterium species will facilitate the study of the relationship between GM and bacteria.

In this study, the results showed that 22 (14.47%) patients had excitant food before the onset of GM. The recent literature reports that bacterial interactions have been confirmed between the breast and gut [ 53 , 54 ]. Li et al. hypothesized that imbalances among the external environment, host, and microbiota lead to the occurrence of GM as follows: External factors disturb the balance between the immune microenvironment and breast flora and induce the release of inflammatory factors and milk secretion, resulting in damage to the mammary epithelium. The positive feedback between the immune and inflammatory reactions eventually induces GM [ 13 ]. The consumption of stimulating foods may disrupt the intestinal flora and induce inflammation. Therefore, patients with GM should be given information regarding disease considerations related to diet, sleep, behaviors, etc., as shown in Table ​ Table1 1 .

Our study has several limitations. First, it cannot be confirmed whether interesting factors such as dietary and lifestyle habits are related to the occurrence and recurrence of GM. Second, the effects of this case management model cannot be assessed by this study. Therefore, there are several directions for our next work, including developing targeted strategies based on the case management model and exploring the effectiveness of this model in GM patients.

In conclusion, this study identified some factors associated with the recurrence of the disease under a case management model. “Low” medication adherence was a significant risk factor for the recurrence of granulomatous mastitis. The patients treated with medication and surgery did not have a reduced recurrence rate compared to those treated with medication alone.

Acknowledgements

Author contributions.

PN, X-RH, and XW conceived and designed the study. YD, YX, and P-YH collected and analyzed the data. YD and YX drafted the paper. PN, XW, and G-FT read and revised the draft critically. YD and YX contributed equally to this work. All authors reviewed the manuscript. All authors read and approved the final manuscript.

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Science and Technology Project of The Health Planning Committee of Sichuan [Grant No. 21PJ134].

Availability of data and materials

Declarations.

This study was approved by the Institution Review Board of Chengdu Women and Children’s Central Hospital Ethical approval (Grant No. B2019 (13)). All participants signed an informed consent form before data collection. All procedures performed in this study were in accordance with the ethical standards.

Not applicable.

The authors declare that they have no competing interests.

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Contributor Information

Ping Ning, Email: moc.361@11gnipn .

Xin Wang, Email: moc.qq@7614715201 .

IMAGES

  1. (PDF) Antibiogram of Milk Sample Clinically Affected from Mastitis: A

    case study mastitis

  2. NCP Case Study Chronic Mastitis sample

    case study mastitis

  3. (PDF) Bacteriological Testing of Milk Samples Suspected of Sub-Clinical

    case study mastitis

  4. (PDF) Granulomatous lobular mastitis: Clinical update and case study

    case study mastitis

  5. Case presentation mastitis

    case study mastitis

  6. Case Study of a Mastitis Investigation in an Automatic Milking System

    case study mastitis

VIDEO

  1. Treatment of mastitis l fibrosis mastitis l dr umar khan

  2. sekawati veterinary College,Bovine mastitis case#viral #shorts

  3. Mastitis Part 6

  4. Ross Vet Diagnostic Lab

  5. Unleashing Comparative Oncology: Cancer Moonshot Progress Video Series

COMMENTS

  1. Acute Mastitis

    [1] Periductal mastitis is a benign inflammatory condition affecting the subareolar ducts and occurs most commonly in reproductive-aged women. Alternatively, IGM is a rare benign inflammatory condition that can clinically mimic breast cancer and occurs primarily in parous women ordinarily within 5 years of giving birth. [1] Go to: Etiology

  2. Incidence of and Risk Factors for Lactational Mastitis: A Systematic

    Lactational mastitis is a maternal morbidity that affects the wellbeing of women and their babies, including through breastfeeding discontinuation. Research Aim To systematically review the available global literature on the frequency of lactational mastitis, and to summarize the evidence on risk factors for lactational mastitis.

  3. Case Report of Recurrent Bilateral Mastitis in a Woman Who Is

    ABSTRACT In this report, we describe a case of bilateral lactational mastitis in a primigravid, Spanish-speaking woman who exclusively pumped breast milk for a hospitalized, critically ill infant in the NICU within a free-standing children's hospital.

  4. Women's experiences of treatment for mastitis: A qualitative study

    The study shows that women who were treated for mastitis were at risk of being admitted to hospital wards characterized by a lack of knowledge about mastitis, insufficient or flawed treatment competence, and an absence of necessary equipment.

  5. A Five-step Systematic Therapy for Treating Plugged Ducts and Mastitis

    Case-control study was performed to observed the differences in clinical response between plugged ducts and acute mastitis after a single FSST. Setting and sample. This study was performed at Guangzhou Women and Children's Medical Center, the largest Women and Children specialized hospital in south China.

  6. Case Report of Recurrent Bilateral Mastitis in a Woman Who Is

    Case Report | Volume 50, ISSUE 6, P765-773, November 2021 Download Full Issue Case Report of Recurrent Bilateral Mastitis in a Woman Who Is Exclusively Pumping Breast Milk for an Infant in the NICU Jessica Schwarz Elizabeth B. Froh Diane L. Spatz Published: August 09, 2021 DOI: https://doi.org/10.1016/j.jogn.2021.07.002

  7. Management of Mastitis in Breastfeeding Women

    Studies have reported the incidence to be as high as 33 percent in lactating women. 3 One study of 946 lactating women, followed prospectively, found an incidence of 9.5 percent. 4 Although ...

  8. Mastitis and Risk of Breast Cancer: a Case Control-Retrospective Study

    Conclusion: Our study showed a relation between mastitis and breast cancer. Mastitis could be a potential risk factor. Further studies with larger number of patients are mandatory in order to confirm this possible relationship. Keywords: breast cancer, mastitis, breastfeeding, breast malignancy, breast cancer risk factors. Go to: INTRODUCTION

  9. A case-control study of mastitis: nasal carriage of Staphylococcus

    Abstract Background Mastitis is a common problem for breastfeeding women. Researchers have called for an investigation into the possible role of maternal nasal carriage of S. aureus in the causation of mastitis in breastfeeding women. Methods The aim of the study was to investigate the role of maternal S. aureus nasal carriage in mastitis.

  10. A lactating woman presenting with puerperal pneumococcal mastitis: a

    Streptococcus pneumoniae is an uncommon etiologic agent in soft-tissue infections. We report the case of a 35-year-old Caucasian woman who presented to our facility with puerperal pneumococcal mastitis, and review the only other three cases of pneumococcal mastitis described in the medical literature. The roles of the various pneumococcal vaccines in preventing this disease are discussed.

  11. A case management model for patients with granulomatous mastitis: a

    Granulomatous mastitis (GM) is a chronic inflammatory mastitis disease that requires long-term treatment and has a high recurrence rate. Case management has been proven to be an effective mechanism in assisting patients with chronic illness to receive regular and targeted disease monitoring and health care service. The aim of this study was to investigate the application of a hospital-to ...

  12. Mastitis

    (Table 1). Most studies have major methodological limitations, and there are no large prospective cohort studies. The higher rates are from selected populations. The incidence of breast abscess also varies widely, and most estimates are from retrospective studies of patients with mastitis (Table 2). However, according to some reports ...

  13. Case Study: Mastitis in Breastfeeding Woman

    Breathing mechanics: Decreased rib mobility, upper back tightness present ROM: Thoracic spine mobility:extension: mod loss, rotation to R/L: mod loss tightness of rib cage/thoracic spine present. Muscle strength: Both UE and LE grossly graded: 5/5 The client presented with tight superficial and deep front arm lines.

  14. mastitis case study

    . mastitis. an infection of bred Vt tissue , usually unilateral I can occur when there's a buildup of milk causing a clogged duct - helps wt unclogging ducts 3 prevents the spread of bacteria .

  15. Case Study on Mastitis in Bovine Milk

    Solution Sequencing and analysis of hypervariable regions within the 16S rRNA gene can provide relatively rapid and cost-effective, large scale methods for assessing bacterial diversity and abundance and is a definite advantage for pathogen discovery and identification.

  16. PDF A Case Study of Clinical Mastitis in a Cow

    Introduction Mastitis is one of the most important economical diseases of dairy cattle (Bramley, 1992)1.Generally, the clinical form of mastitis divided into mild, moderate or severe. In mild cases, visible abnormality is limited to the milk only i.e. clots, flakes or watery milk.

  17. A case-control study of mastitis: nasal carriage of Staphylococcus

    A case-control study of mastitis: nasal carriage of Staphylococcus aureus We found no association between maternal nasal carriage of S. aureus and mastitis, but nasal carriage in the infant was associated with breast infections. As in other studies of mastitis, we found a strong association between nipple damage and mastitis.

  18. Mastitis Case Study: A 36 yo post-partum patient comes to the

    Answer & Explanation Solved by verified expert Answered by ChefHeat19630 on coursehero.com ICD Codes, Differential Diagnosis, and Rationale for Their Use 1. Mastitis Mastitis, also known as mastitis, is an infection of the breast tissue that can be caused by a fungal or bacterial infection.

  19. A case-control study of mastitis: nasal carriage of Staphylococcus

    Methods. The aim of the study was to investigate the role of maternal S. aureus nasal carriage in mastitis.Other factors such as infant nasal S. aureus carriage, nipple damage, maternal fatigue and oversupply of milk were also investigated.A case-control design was used. Women with mastitis (cases, n = 100) were recruited from two maternity hospitals in Melbourne, Australia (emergency ...

  20. CLINICAL MASTITIS IN A CROSS BRED COW: A CASE STUDY

    The study was carried out to determine the prevalence of mastitis in lactating cows in some selected commercial dairy farms in Sokoto metropolis. A total of 100 milk samples were collected from ...

  21. A case management model for patients with granulomatous mastitis: a

    A case management model for patients with granulomatous mastitis was applied to effectively monitor changes in the disease and to identify factors associated with disease recurrence. "Low" medication adherence was a significant risk factor for the recurrence of granulomatous mastitis.

  22. Therapeutic Management of Clinical Mastitis in Goat: a Case Study

    Case Study, Clinical Mastitis, Therapeutic Management, Goat. Clinical mastitis is a common and economically s ignificant disease in . dairy animals. A doe with clinical mastitis was brought tothe .

  23. Case presentation mastitis

    Case presentation mastitis afrahDH Feb 15, 2019 • 8 likes • 7,208 views Health & Medicine 5th year medical student _ Tabuk University 1 of 20 Download Now Recommended Obstetric case study QURATULAIN MUGHAL Case presentation post caesarean pregnancy ymadhu326 A case of acute Pelvic Inflammatory Disease (PID) Dr.Emmanuel Godwin