Management of idiopathic granulomatous mastitis in lactation: case report and review of the literature

Abstract

Background Idiopathic Granulomatous Mastitis (IGM) is a benign chronic inflammatory breast condition that mimics two common breast disorders: breast carcinoma and breast abscess. It can form breast masses, fistulae, and fluid collections, resulting in breast disfigurement with retraction and nipple areolar complex (NAC) inversion. IGM most often presents in women of childbearing age within a few years of pregnancy, and can significantly impact lactation. Despite the prevalence of this disease, no current literature describes an approach to managing IGM during breastfeeding. Case presentation A 28-year-old G3P2 patient of Native American origin presented to her obstetrician at 7 months pregnant with worsening left breast swelling and redness. She underwent a mammogram, ultrasound and core needle biopsy that confirmed the diagnosis of Idiopathic Granulomatous Mastitis. During the postpartum period, she underwent intralesional triamcinolone injections of her left breast. Due to the contraindication of breastfeeding after local steroid injection, the patient stopped breastfeeding from the affected breast and continued breastfeeding unilaterally. Conclusions Idiopathic Granulomatous Mastitis is a challenging chronic inflammatory breast disease that affects women primarily in the reproductive years, with a higher incidence in patients of Hispanic, Native American, Middle Eastern, and African descent. Treatment of IGM during pregnancy and lactation has thus far not been addressed. We review the literature on the treatment of IGM in the non-lactating population, and propose considerations for treating breastfeeding women affected by this disease. Traditional treatment has included systemic immunosuppression and surgery, but newer literature demonstrates that intralesional injection of steroid can provide significant symptomatic relief to patients. A diagnosis of IGM does not preclude breastfeeding, though patients may experience challenges with milk production and latch on the affected breast. Individualized care should be provided, with considerations given to the following: side effects of systemic steroids, the need to wean a breast being treated with intralesional steroids, and augmentation of milk production on the unaffected breast to promote continued breastfeeding.

Common Complications of Breastfeeding and Lactation: An Overview for Clinicians

“…Until afebrile for 24 h or culture and sensitivities available First-line treatment if abscess condition of the breast that can arise during pregnancy, lactation, or in the years following lactation and can be easily mistaken for a breast abscess or carcinoma. 14,19 The etiology of IGM is unclear but may arise from subclinical infection, autoimmune processes, or breast trauma. Elevated levels of serum prolactin are observed in nonlactating individuals who present with IGM, suggesting a relationship between distended alveoli and granulomatous response.…”

“…Some authors describe aspirating lesions and injecting dilute steroid into regions of active disease as an effective means to avoid systemic treatment. 19 IGM may arise during pregnancy or lactation and there is no evidence that breastfeeding impairs or prolongs disease resolution, however, use of systemic steroids is known to reduce milk supply. Given the unilateral disease distribution, it may be possible for some individuals to wean the affected breast and continue to feed or pump from the contralateral side.…”

“…Despite reports of various bacterial cultures from lesion aspirate, the current understanding is that the condition is inflammatory not infectious and recent literature recommends against repeated courses of antibiotics, which many people are given before diagnosis. Some authors describe aspirating lesions and injecting dilute steroid into regions of active disease as an effective means to avoid systemic treatment 19. IGM may arise during pregnancy or lactation and there is no evidence that breastfeeding impairs or prolongs disease resolution, however, use of systemic steroids is known to reduce milk supply.…”

“…Idiopathic granulomatous mastitis (IGM) is a benign, chronic inflammatory condition of the breast that can arise during pregnancy, lactation, or in the years following lactation and can be easily mistaken for a breast abscess or carcinoma 14,19. The etiology of IGM is unclear but may arise from subclinical infection, autoimmune processes, or breast trauma.…”

“…While many pregnant people have intention to breastfeed, few ultimately achieve the recommended duration and exclusivity. According to the Centers for Disease Control and Prevention (CDC), of infants born in the United States in 2017 19.2% received formula before 2 days of age, 58.3% were breastfeeding at 6 months, however, only 25.6% were exclusively breastfeeding at 6 months, and only 35.3% were breastfeeding at 1 year. 1 The CDC estimates that suboptimal population breastfeeding rates in the US adds $3 billion in excess medical costs for women and children, primarily because of excess infectious morbidity for infants but also in long-term chronic disease burden.…”