Breast and Endocrine
CASE 39: breaSt inFeCtion
history
A 26-year-old woman who is 5 weeks post partum presents with right breast pain and a fever. She is breast-feeding her son. Over the past 3 weeks she has seen her general practitioner (GP) on two occasions with mastitis and has been prescribed antibiotics. However, the pain is now worsening and she is starting to feel more unwell. She is normally fit and healthy. She does not take any regular medications and is allergic to penicillin.
examination
She has a temperature of 37.9°C and a pulse rate of 92/min. On examination, there is a localized, tender area, adjacent to the areola of the right breast. There is surrounding erythema and tender lymphadenopathy in the right axilla.
INVESTIGATIONS
|
|
Normal |
haemoglobin |
11.3 g/dl |
11.5–16.0 g/dl |
mean cell volume |
86 fl |
76–96 fl |
White cell count |
16.8 × 109/l |
4.0–11.0 × 109/l |
neutrophils |
12.8 × 109/l |
1.7–6.1 × 109/l |
platelets |
345 × 109 |
150–400 × 109/l |
Questions
•What is the likely diagnosis?
•What other investigations would you arrange?
•What are the treatment options, and what other considerations do you have to make when prescribing?
•What other advice would you give regarding her breast-feeding?
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100 Cases in Surgery
ANSWER 39
This woman has a puerperal breast abscess. Mastitis occurs frequently in lactating females. Infection is most common in the first 6 weeks post partum. This is the result of organisms entering through traumatized skin and cracked nipples. It is usually treated with antibiotics, and mothers are advised to continue expressing from the breast to aid drainage through the ducts. Occasionally the infection can progress and lead to a breast abscess. The most commonly involved organisms are Staphylococcus aureus and the Streptococcus species.
Non-lactating breast abscesses occur most commonly around the age of 30 years and are often associated with duct ectasia. Periareolar abscesses are found to be associated with smoking, whereas peripheral abscesses are more common in immunosuppressed women, such as those taking steroids or patients with diabetes.
In this case, other investigations would include anaerobic and aerobic cultures taken from the abscess. These can usually be obtained by needle aspiration under ultrasound guidance.
Treatment is either by recurrent needle aspiration or rarely by incision and drainage. Antibiotics should be continued. Flucloxacillin (or erythromycin if the patient is penicillin allergic) is recommended, but the choice of antibiotic should be guided by the culture results. Co-amoxiclav is prescribed in non-lactating breast abscesses where anaerobes and enterococci may also be causative. Appropriate analgesia should also be prescribed. It is imperative to remember that this patient is breast-feeding, and the British National Formulary (BNF; see Appendix 4 therein) should be consulted before prescribing to ensure there are no contraindications.
KEY POINT
•it is important to note that if the inflammation or mass persists after treatment, then the possibility of breast cancer should be ruled out with further imaging and tissue sampling.
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Breast and Endocrine
CASE 40: SWelling in the neCK
history
A 45-year-old woman is referred to the general surgical outpatients after her GP noticed a swelling in the neck. On questioning, the patient reports losing about a stone in weight over the preceding 3 months, despite having an increased appetite. She also complains that she always feels hot and has to sleep on top of the bed covers at night. Her bowel motions have been loose.
examination
The patient is thin, irritable and has a noticeable fine resting tremor. Her peripheries feel warm and she has a resting heart rate of 110/min, with a blood pressure of 150/90 mmHg. On examination of the neck, there is a smooth moderate enlargement of the thyroid gland, which moves on swallowing. There is protrusion of the eyes with lid retraction. Her visual acuity and eye movements are normal. There is no associated lymphadenopathy. The heart sounds are normal and the chest is clear.
INVESTIGATIONS
|
|
Normal |
haemoglobin |
12.0 g/dl |
11.5–16.0 g/dl |
mean cell volume |
77 fl |
76–96 fl |
White cell count |
10.4 × 109/l |
4.0–11.0 × 109/l |
platelets |
250 × 109/l |
150–400 × 109/l |
Sodium |
137 mmol/l |
135–145 mmol/l |
potassium |
3.7 mmol/l |
3.5–5.0 mmol/l |
urea |
5 mmol/l |
2.5–6.7 mmol/l |
Creatinine |
79 μmol/l |
44–80 μmol/l |
thyroid-stimulating hormone (tSh) |
0.01 mu/l |
0.5–5.7 mu/l |
tri-iodothyronine (t3) |
17 pmol/l |
2.5–5.3 pmol/l |
thyroxine (t4) |
42 pmol/l |
9–22 pmol/l |
Questions
•What are the causes of a goitre?
•What is the likely diagnosis in this patient?
•What are the options for treatment?
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100 Cases in Surgery
ANSWER 40
A goitre is an enlargement of the thyroid gland. It can be diffuse or multinodular in origin.
!Causes of goitre
•Diffuse:
•physiological: puberty/pregnancy
•autoimmune: graves’ disease/hashimoto’s thyroiditis
•inflammatory: De Quervain’s (acute) thyroiditis/riedel’s (chronic) thyroiditis
•iodine deficiency: colloid/simple
•goitrogens: carbimazole/propylthiouracil
•lymphoma
•multinodular/solitary nodule:
•multinodular goitre
•Cysts
•tumours: adenomas/carcinoma
•miscellaneous: sarcoidosis/tuberculosis
This patient has hyperthyroidism secondary to Graves’ disease. The TSH levels are suppressed and there are increased levels of free T3 and T4. Graves’ disease most commonly develops in women aged between 30 and 50 years, and is caused by circulating stimulating antibodies to the thyroid receptors (long-acting thyroid stimulator [LATS]). Patients often present with many symptoms including palpitations, anxiety, thirst, sweating, weight loss, heat intolerance and increased bowel frequency. Enhanced activity of the adrenergic system also leads to agitation and restlessness. Approximately 25–30 per cent of patients with Graves’ disease have clinical evidence of ophthalmopathy. This almost only occurs in Graves’ disease (very rarely found in hypothyroidism) and is also due to autoantibody damage leading to swelling of the orbital fat and connective tissue. Low titres of microsomal and thyroglobulin antibodies are also often present in patients with Graves’ disease.
Many patients are now treated with radio-iodine therapy. Antithyroid medication, carbimazole or propylthiouracil, are used to establish control of hyperthyroidism and act by inhibiting thyroid hormone production. Beta-blockers may also be used initially to control symptoms. Surgery is indicated in patients with a large goitre, in patients with recurring disease and in patients unable to have radio-iodine therapy (patients planning pregnancy). There is a surgical risk of damage to the recurrent laryngeal nerve (1 per cent), hypocalcaemia (1 per cent) and hypothyroidism (10 per cent).
KEY POINTS
•graves’ disease is caused by antibodies to the thyroid receptors.
•up to 30 per cent of patients with graves’ disease have eye signs.
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