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Table of Contents
CASE REPORT
Year : 2022  |  Volume : 27  |  Issue : 2  |  Page : 201-203

Bloody nipple discharge in a 5-month-old female: A case report of mammary ductal ectasia from subclinical mastitis


1 Department of Paediatrics, Ahmadu Bello University Teaching Hospital Shika, Zaria, Nigeria
2 Division of Paediatric Surgery, Department of Surgery, Barau Dikko Teaching Hospital/Kaduna State University, Nigeria

Date of Submission04-Jun-2021
Date of Decision03-Jul-2020
Date of Acceptance11-Jun-2021
Date of Web Publication3-Mar-2022

Correspondence Address:
Maria Ahuoiza Garba
Department of Paediatrics, Ahmadu Bello University Teaching Hospital Shika, Zaria.
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmh.IJMH_22_21

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  Abstract 

Mammary ductal ectasia (MDE) is both rare and benign in children. Less than 50 cases have so far been reported in the literature. It often presents as bloody nipple discharge (BND) and results in significant parental anxiety. Although mostly thought to be developmental in origin, the practice of pressing breast swellings in neonates and infants could potentially predispose the breast tissues to infection. Lack of awareness of MDE among healthcare providers may result in unnecessary, expensive, and even invasive investigations. We report a case of MDE presenting as BND and subclinical mastitis in a 5-month-old girl.

Keywords: Bloody nipple discharge, infants, mammary ductal ectasia


How to cite this article:
Garba MA, Akau SK, Laila H. Bloody nipple discharge in a 5-month-old female: A case report of mammary ductal ectasia from subclinical mastitis. Int J Med Health Dev 2022;27:201-3

How to cite this URL:
Garba MA, Akau SK, Laila H. Bloody nipple discharge in a 5-month-old female: A case report of mammary ductal ectasia from subclinical mastitis. Int J Med Health Dev [serial online] 2022 [cited 2022 May 24];27:201-3. Available from: https://www.ijmhdev.com/text.asp?2022/27/2/201/339028




  Introduction Top


Bloody nipple discharge (BND) is a cause of concern for both parents and physicians because of its likely association with malignancy. A recognized cause of BND is mammary ductal ectasia (MDE) which is a completely benign, rare, and self-limiting disorder in children.[1],[2] A literature search of Scopus, PubMed, Google Scholar, and Embase showed that less than 50 of such cases have been reported in the literature. Lack of awareness of MDE among healthcare providers may result in unnecessary, expensive, and even invasive investigations and treatments. Although mostly thought to be developmental in origin, the practice of pressing breast swellings in neonates and infants could potentially predispose to infection and subsequent ductal dilatation, supporting the role of microorganisms in its etiopathogenesis.


  Aim Top


To report a case of MDE from subclinical mastitis in a 5-month-old infant presenting as BND.


  Case Report Top


A 5-month-old girl presented on July 30, 2020 with complaints of left-sided BND of 2 days. It was first noticed as a spot on her dress and subsequently, when pressure was applied, on the areola. There was no preceding discharge, pain, color change, or differential warmth. She had a history of bilateral breast swelling observed from birth for which a warm compress was applied frequently up until she was 40 days old. There was no application of topical medication. She had no fever, was not fretful, and was feeding well.

Her mother was a known hypertensive managed with oral nifedipine from the second trimester. She had not been on hormonal medications before or during pregnancy. She had no known family history of endocrine or breast diseases. Our patient was delivered at term with a birth weight of 3.0 kg. She was being exclusively breastfed and was fully vaccinated for age.

Examination finding was that of a well-preserved infant whose length and weight were above the 90th centile for age and sex. She was afebrile, not pale, and had no dysmorphic features. She had bilateral, firm, non-tender breast masses which measured approximately 2.0 × 2.0 cm, with the appearance of a blood spot on the left breast when slight pressure was applied. There was no differential skin coloration or warmth. An initial diagnosis of left mastitis was made.

Ultrasonography of the breast showed a hypo-echoic lesion of irregular margins and septate at the base of the left nipple which measured 8.7 × 4.4 mm. There was no vascular flow in it or probe tenderness [Figure 1]. The remaining breast tissue appeared normal. These features were suggestive of ductal ectasia. Her full blood count showed a packed cell volume of 36%, white blood count of 5.8 × 109/L, neutrophils of 65%, lymphocytes of 35% with a left shift, and C-reactive protein of <5.0 mg/dl. Microscopy of the nipple discharge showed numerous red blood cells, pus cells of 4–8/hpf, whereas culture yielded Staphylococcus epidermidis.
Figure 1: Hypo-echoic lesion with irregular margins and septae at the base of the left breast measuring 8.7 x 4.4 mm

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She was placed on 125 mg of cefuroxime axetil for 1 week. By the 4th day, the BND had ceased and had not recurred 6 weeks later when she was followed up. The breast swellings had regressed and a repeat breast ultrasound at the visit showed complete resolution of the lesion. She has maintained regular follow-up care.


  Discussion Top


BND is rare among infants with only a few cases reported in the literature.[1] It is a significant cause of concern for parents and physicians. While it may be associated with intraductal papilloma in adults, the commonest cause in children is MDE, a benign condition that is characterized by dilatation of the lumen of the mammary ducts and thickening of its walls, periductal fibrosis, and inflammation.[1] Other possible causes of BND include trauma, mastitis, intraductal cyst, mammary ductal hyperplasia, infantile gynecomastia, complicated lymphangioma, and ductal papillomatosis.[1],[2],[3],[4]

MDE was first described by Berkowitz and Inkelis[2] in 1983 in a boy and girl, both 6-week-old. Forty years on, the exact cause is still being debated. It has been theorized that the etiology is multifactorial with hormonal, developmental, and infective factors at play.[1],[3],[4] Dixon et al.[4] suggest that periductal mastitis precedes dilation of the ducts in younger patients. This is based on the histological finding of marked inflammation surrounding even non-dilated ducts in younger children.[4] In comparison, there is no infiltration of the stroma with inflammatory cells in the presence of marked ductal dilatation and even nipple retraction among older subjects, suggesting that dilatation is the primary lesion.[4]

Our patient had bilateral breast swellings from birth, likely physiologic/maternal hormonal induced, which had been subjected to warm water compress to remove the mother’s milk from the child’s breast, a common neonatal practice in Africa.[5] This practice likely caused the retrograde spread of bacteria into the breast tissues,[6] causing the ducts to be infected with S. epidermidis, a normal skin commensal. Although the strain of S. epidermidis was not typed in this case, some strains can cause low-grade virulent and chronic infection through evading the body’s immune system by the formation of biofilms which serve as a protective layer, thereby decreasing the hosts’ inflammatory response.[7] This could account for the delay in the appearance of BND. It has been reported that S. epidermidis biofilm-grown strains elicit production of anti-inflammatory rather than pro-inflammatory cytokines, a fact that can account for the low CRP value in our patient as pro-inflammatory cytokines such as interleukin-6 and TNF-α are important drivers of CRP production.[8]

MDE has been reported to be self-limiting with the resolution of BND occurring within 2 weeks to 9 months in children.[1],[9],[10] The BND ceased in our patient by the 4th day. This further supports infection as a cause and is likely the shortest duration of BND from MDE so far reported as shown by a literature search using the following search engines: PubMed, Embase, Google Scholar, and Scopus.

Seo et al.[10] had also cultured S. epidermidis from a 4-month-old with similar findings but had discarded it as a possible contaminant. Similarly, Kitahara et al.[3] had considered their positive culture insignificant due to lack of clinical and histologic evidence of an abscess and other signs of inflammation.

A careful physical examination, cytology, gram stain, culture of the discharge, and ultrasonographic evaluation are recommended in addition to a clinical follow-up. Only if ultrasonography reveals a mass or an abnormality other than MDE, or if the discharge persists beyond 9 months, further investigations, including invasive interventions, should be considered.[1],[9],[10]


  Conclusion Top


MDE is rare and benign in infants. The traditional practice of warm compressions may have triggered a low-grade infection culminating in MDE as presented. Careful history and evaluation are required to avoid unnecessary investigations and waste of resources. The possibility of indolent infections should be entertained as antibiotics prescribed based on bacteriologic sensitivity may shorten the duration of BND.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Jung Y, Chung JH. Mammary duct ectasia with bloody nipple discharge in a child. Ann Surg Treat Res 2014;86:165-7.  Back to cited text no. 1
    
2.
Berkowitz CD, Inkelis SH. Bloody nipple discharge in infancy. J Pediatr 1983;103:755-6.  Back to cited text no. 2
    
3.
Kitahara S, Wakabayashi M, Shiba T, Nonaka K, Nonaka H, Kobayashi I. Mammary duct ectasia in children presenting bloody nipple discharge: A case in a pubertal girl. J Pediatr Surg 2001;36:E2.  Back to cited text no. 3
    
4.
Dixon JM, Anderson TJ, Lumsden AB, Elton RA, Roberts MM, Forrest AP. Mammary duct ectasia. Br J Surg 1983;70:601-3.  Back to cited text no. 4
    
5.
Wammanda RD. Bilateral neonatal breast enlargement associated with mastitis. Ann Afr Med 2004;3:45.  Back to cited text no. 5
    
6.
Nguyen TH, Park MD, Otto M. Host response to Staphylococcus epidermidis colonization and infections. Front Cell Infect Microbiol 2017;7:90.  Back to cited text no. 6
    
7.
Heilmann C, Ziebuhr W, Becker K. Are coagulase-negative Staphylococci virulent? Clin Microbiol Infect 2019;25: 1071-80.  Back to cited text no. 7
    
8.
Brown JVE, Meader N, Wright K, Cleminson J, McGuire W. Assessment of C-reactive protein diagnostic test accuracy for late-onset infection in newborn infants: A systematic review and meta-analysis. JAMA Pediatr 2020;174:260-8.  Back to cited text no. 8
    
9.
Weimann E. Clinical management of nipple discharge in neonates and children. J Paediatr Child Health 2003;39:155-6.  Back to cited text no. 9
    
10.
Seo JY, Kim SJ, Lee SJ, Song ES, Woo YJ, Choi YY. Bloody nipple discharge in an infant. Korean J Pediatr 2010;53:917-20.  Back to cited text no. 10
    


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