Bilateral Breast Abscess in a Newborn Baby

Background: In this study we wish to attract attention to mistaken interventions to the breast tissue of neonates and to increase awareness about this topic among personnel providing health services to neonates. Case presentation: A fourteen-day male infant was brought to the pediatric emergency clinic with swelling, redness, hardness and discharge complaints in the region of both breasts. Ultrasonography of the breast tissue of the patient identied appearance compatible with a dense-content abscess in the form of hyperechoic or hypoechoic avascular mass. Bilateral breast abscess responded to surgical and medical treatment. Conclusions: It is important to recognize physiological breast hypertrophy in newborns. In physiological hypertrophy, the breast bud is neither red nor soft and heals spontaneously. No intervention is required.


Background
In both sexes, temporary neonatal breast hypertrophy is frequently observed due to the effect of maternal and placental hormones. This hypertrophy is thought to be triggered linked to prolactin release in the neonate caused by the fall in maternal estrogen levels after pregnancy (1). This temporary breast growth generally begins a few days after birth in the neonate and regresses on its own in maximum 4-6 months.
There is no erythema or temperature increase.
Mastitis and breast abscess are very rarely observed in the neonatal period (2). Skin colonization of the neonate begins with birth. As the skin is thin and immunity is insu cient, compression of breast tissue and massage of the breast may cause mastitis and breast abscess (3). Mastitis may ameliorate with antibiotherapy; however, if infection spreads and causes abscess in the breast, surgical drainage should be performed. Infection is frequently localized and may cause cellulitis, osteomyelitis, meningitis, brain abscess and sepsis (2,(4)(5)(6). In this study we wish to attract attention to mistaken interventions to the breast tissue of neonates and to increase awareness about this topic among personnel providing health services to neonates.

Case Presentation
A fourteen-day male infant was brought to the pediatric emergency clinic with swelling, redness, hardness and discharge complaints in the region of both breasts.
With no problems on antenatal follow-up, the case was the 38-year old mother's rst pregnancy, born weighing 3200 g at term and by cesarean. The patient was observed to have swelling of both breasts after birth and the mother massaged this region. Two days before, swelling, redness, hardness and discharge complaints were observed to develop in the region of both breasts.
Physical examination found general status good, with vibrant neonatal re exes, body temperature 36.5 ℃, peak heart rate 140/min, respiratory rate 38/min, and blood pressure 78/44 mmHg. Both breasts had clear hyperemia, hardness, uctuations causing swelling and temperature increase, with breast dimensions 3 × 3 cm, with other system aspects assessed as normal (Fig. 1).
Ultrasonography of the breast tissue of the patient identi ed appearance compatible with dense-content abscess in the form of hyperechoic or hypoechoic avascular mass (Fig. 2, Fig. 3).
With breast abscess identi ed, the patient had drainage performed and sent for culture and antibiogram.
Empirical vancomycin and cefotaxime treatments were begun intravenously. The abscess content was observed to have gram positive cluster cocci on gram staining. Culture produced methicillin-susceptible Staphylococcus aureus. The patient had cefotaxime treatment stopped on the 3rd day and continued with vancomycin.
On follow-up, swelling of both breasts appeared to be fully ameliorated by the 10th day ( Fig. 4). There was no proliferation in blood culture. Repeated tests identi ed amelioration in CRP elevation.
With no additional problem during follow-up, the case completed antibiotherapy in 10 days and was discharged.

Discussion And Conclusions
The breast tissue infection of mastitis and association with abscess is very rare in the neonatal period.
Generally, it is observed in term infants. The rarer observation in preterm infants is thought to be linked to less development of breast tissue (2,4,7).
It is observed in the rst 1-6 weeks of life, with incidence increasing in the 2nd -3rd weeks (5,(8)(9)(10)(11). Mostly unilateral, there are cases with bilateral mastitis developing in the literature, as in our case (12,13). Generally, it is observed 2 times more in girls; however, no sex difference was determined for the rst two weeks of life. This situation is thought to be linked to the physiological breast growth in girls being observed more after the second week.
The pathogenesis of mastitis is not fully known. However, infection is thought to develop mostly from skin ora entering the nipple with retrograde spread via the ductal canals (2,7). In the literature, there are cases reporting mastitis and breast abscess in the infants of breastfeeding mothers with postpartum breast abscess. In these cases, the mastitis vector is the mother was identi ed to be the same as in the infant. It is thought that microorganisms in breastmilk cause bacteremia in the infant leading to mastitis and breast abscess. Among vectors identi ed in reported cases are methicillin-resistant Staphylococcus aureus and group B streptococci (14,15). When our patient is assessed in terms of the mother, there were no symptoms or ndings leading to consideration of mastitis or abscess in the mother. Abscess formation is reported in 40-70% of infants with mastitis and generally is observed in cases with insu cient treatment (2,4,7).
Initially breasts are identi ed to have growth, erythema, induration, tension and temperature increase. The skin around the affected breast tissue changes and axillary lymph node growth may be observed. If abscess formation develops, uctuation may be taken (7). In our case, 2 days before admission, erythema and swelling had begun in the breasts and bilateral breast abscess was identi ed. Elevated fever, restlessness and toxic appearance is present in 30% of patients. Leukocytosis and CRP elevation is observed in 50-70% of cases (2,8). In 83-88% of cases, the vector is Staphylococcus aureus (2,4,8,12). Other vectors are gram negative organisms like Escherichia coli, Klebsiella, Shigella, Salmonella and Pseudomonas (4,7,11,14,16). Infections formed by anaerobic peptostreptococci, Staphylococcus epidermis, Group D and B streptococci are reported (12,14). Anaerobic vectors are identi ed in 40% of cases; however, the place in the etiology is controversial and it is not recommended to start direct antibiotherapy for these vectors (8,9). Abscess linked to Staphylococcus aureus may be observed especially in the periumbilical and perineal regions on the trunk as pustular and bullous lesions (4).
Symptoms, onset age and clinical ndings are similar to infections linked to gram negative basilar and anaerobic vectors and staphylococcic infections. Cases infected with salmonella strains may have gastrointestinal ndings observed (11). Infants with subclinical mastitis may be restless and cry excessively and be diagnosed with infantile colic (17). In our cases, the initial symptoms noticed by the family were redness and swelling of the two breasts. The patient was assessed in terms of galactorrhea due to discharge from the left breast. FSH, LH, E2 and prolactin levels were within normal limits.
Clinical assessment is the rst stage of diagnosis. Ultrasonography is important for assessment of cases developing abscess especially. Abscess diagnosis may be made in the presence of uctuation; however, uctuation may not be observed in the presence of induration. The nding for mastitis on ultrasonography is increased echogenicity. Abscess provides ndings of hyperechoic or hypoechoic avascular mass (18).
Gram staining and culture results direct treatment. If uctuation is present, the abscess should de nitely be drained. In situations without abscess, antibiotherapy alone is curative. Warm compresses may be bene cial. Initially, β lactamase-resistant anti-staphylococcal antibiotics should be chosen; however, in locations with high incidence of MRSA infection, vancomycin or clindamycin may be started. If gram negative basilar is observed on gram staining or if no microorganism is observed, and the infant has septic appearance, initial treatment should have aminoglycoside or cefotaxime added. In our case, due to the bilateral abscess and high infection symptoms, empirical vancomycin and cefotaxime treatment was begun intravenously. Cefotaxime treatment was stopped according to culture and antibiogram results and vancomycin continued. In most cases, 5-7 days of treatment is su cient; however, treatment may be extended to 10-14 days according to the isolated vector, patient's clinical status and presence of bacteremia.
The most common complication of neonatal mastitis is cellulitis observed at rates of 5-10%. Generally, it is localized; however, it may rarely spread to the shoulder and abdomen (2,10). Other rare complications are fasciitis, osteomyelitis, meningitis, cerebral abscess and sepsis (2,(4)(5)(6). There is no de nite data related to late period complications, but even in cases treated appropriately some cosmetic problems like scar development, hypoplasia and asymmetry may occur. It may cause problems with breast development in adolescent girls.
As a result, families should be informed about physiological breast hypertrophy and galactorrhea and mistaken interventions should be prevented.  Both breasts had clear hyperemia, hardness, uctuations causing swelling and temperature increase, with breast dimensions 3 x 3 cm, with other system aspects assessed as normal Figure 2 Right breast abscess-Ultrasonography of the breast tissue of the patient identi ed appearance compatible with dense-content abscess in the form of hyperechoic or hypoechoic avascular mass Left breast abscess-Ultrasonography of the breast tissue of the patient identi ed appearance compatible with dense-content abscess in the form of hyperechoic or hypoechoic avascular mass Figure 4 swelling of both breasts appeared to be fully ameliorated by the 10th day