Case presentation mastitis

5th year medical student _ Tabuk University

1. OBGyne Case presentation Done by : Afrah Dhaifallah Elaf Ibrahim Norah Abdurrahman

2. Personal Hx Mona, 29 years old Saudi housewife, married for 5 years G2P2+0 , 2 previous CS , She is breast-feeding Originlly from Al- madina and living in Tabuk With no special habits of medical importance Her husband 35 years old , Teacher , non smoker

3. Chief Complain She came to the ER complaining of fever since 2 days

4. HPI She had a Caesarean section 3 weeks ago and was recovering well 2 days ago she became very cold and shivery at night. She has been unable to keep herself warm despite several blankets and has reduced appetite , nausea , vomiting and lethargy . In the last 24 h she noticed that left breast become painful , red & hot . pain is sharp , progressive & sever , aggravated by touching it & bowing , no relieving factors She developed mild lower abdominal pain at the site of the Caesarean section wound. She no longer has vaginal bleeding but has a moderate brown discharge with an odour which she says is improving. Bowel habit is normal and she has no urinary symptoms .

5. Gynecologic Hx : No history of : 1- breast disease and breast self exam . 2- previous gynecologic surgery . 3- infertility . 4- using contraceptive . No method of treatment used before and this is the first time to present her self to the hospital with the same condition .

6. Menstrual HX : Her menarche has occurred at the age of 14 years since that time she has regular cycle occurring every 30 days it lasts about 6 days , dark red in color , she changes her pads 4 times per day . associated with dysmenorrhea in first 1 days , No intermenstrual pain or discharge , No Bleeding after sexual intercourse or in between the period . - First day of LMP: 5 / 1/ 2016 .

7. Obstetric Hx

8. G2P2+0 Note NICU lactation Weight Mode Outcome & Date of delivery G. age Her pregnancy was Spontaneous Not planned No contraceptive No complication during pregnancy No intra- post partum complication No For 1 year 2.6 Kg Elective C.s Due to contracted pelvis Boy 3 years ago 38 week 1 Spontaneous planned No contraceptive No complication during pregnancy No intra partum complication No Tell now 2.3 kg Elective C.s Due to contracted pelvis Girl 28/9 /2016 38 week 2

9. Past & Family History Past Hx : No history of any medical disease (Hypertension, DM, epilepsy , thyroid ) No history of previous surgical operation . No history of blood transfusion . No history of drug , food allergies . Family Hx : No family history of DM , HTN and breast / ovarian cancer . No family history of Congenital anomaly . No hx of twins

10. Social Hx - She doesn’t drink alcohol or smoke - She lives in a well ventilated house - Good socioeconomic status - No animal contact - No exercise - No HX of traveling

11. Summary - Mona , 29 years old -She had a Caesarean section 3 weeks ago - Until 2 days ago she started to have : * fever * reduced appetite * nausea, vomiting and lethargy. * In the last 24 h she has noticed the left breast has become painful and red & hot * She has mild lower abdominal pain at the site of the Caesarean section wound. * Bowel habit is normal and she has no urinary symptoms.

12. What is your Differential diagnosis ?

13. Examination - temperature is 38.6°C . - Blood pressure is 120/64 mmHg - heart rate 106 b/min . - The chest is clear and heart sounds are normal. - redness , hotness & Tenderness over the superiolateral aspect of the left breast & No dicharge - The right breast is normal - Normal lymph node examination - Abdomen soft & lax - Mild tenderness over caesarean section incision no redness, hotness, swelling or discharge - The uterus is firm and is non-tender - No leg swelling.

14. Investigation - CBS : Hb : 10.1 g/dl WBC : increased * mainly neutrophils * Platelet : slightly increase - C-reactive protein : 203 * < 5 mg/L - Na & K : within normal - Urinalysis : +++ blood Leukocyte negative Nitrate negative Protein trace

15. what is the diagnosis ? Other investigation ? How would you manage ?

16. Diagnosis The diagnosis is mastitis ( a localized infection within the breast tissue ). This occurs in 5% of lactating women . The pathophysiology probably involves colonization of the breast ducts by bacteria through the cracked nipples, causing localized inflammation and obstruction of the duct with subsequent retention of milk, and infection. The commonest organism is staphylococcus from the skin. The differential diagnosis is of a breast abscess which would be palpated as a fluctuant mass in the breast .

17. Investigation Blood cultures and a swab from the breast milk or nipple are necessary . In cases of diagnostic doubt , an ultrasound scan can differentiate mastitis from an abscess.

18. Management 1- Antibiotics * table * 2- Analgesia ( Acetaminophen , ibuprofen   ) 3- anti-emetic 4- continue breast-feeding. if this is too painful she should express milk in order to try to unblock the duct .

19. Antibiotics Inpatient treatment Outpatient options Nafcillin  2 g IV q4h or Oxacillin  2 g IV q4h If beta-lactam allergy or MRSA suspicion: Clindamycin  600 mg IV q8h or Vancomycin  15 mg/kg IV q12h Dicloxacillin   500 mg for 10-14 days or Cephalexin   500 mg for 10-14 days If beta-lactam allergy: Clarithromycin 500 mg for 10-14 days If suspected (CA-MRSA) infection: Clindamycin   300 mg for 10-14 days