Pathophysiology of

Mastitis

 In lactational mastitis, milk stasis or

milk overproduction, coupled with
infection from bacteria entering the
breast via a traumatised nipple (e.g.,
cracked or fissured) and/or from the
infant's mouth, can lead to mastitis.
Transient breast enlargement from
maternal hormones in neonates
makes them vulnerable to mastitis.

 In duct ectasia (dilated ducts associated

with inflammation), the mammary ductassociated inflammatory disease sequence
involves squamous metaplasia of lactiferous
ducts. This causes blockage (obstructive
mastopathy) with peri-ductal inflammation
and possible duct rupture. Inflamed ducts
are prone to bacterial infection. Left
untreated, mastitis may cause tissue
destruction resulting in an abscess.

 A lactational abscess tends to be located

in the peripheral breast. Abscesses
unrelated to breastfeeding are more
commonly sub-areolar in location. An
abscess may also occur without apparent
preceding mastitis. Rupture of an abscess
can lead to a draining sinus with a
resulting fistula. In tubercular mastitis,
mycobacterial bacilli can enter the breast
from:

 Direct inoculation (primary infection)

via a nipple abrasion
Distant portals (secondary infection),
such as lymphatic spread,
haematogenous (miliary)
dissemination, or contiguous spread
(e.g., empyema necessitans).

 TB of the breast may present with a nodular,

diffuse, or sclerosing reaction. The most common
presentation is a painless lump with or without a
sinus tract. Most cases of tuberculous mastitis are
secondary, and infection occurs via contiguous
spread from lymphatics (most commonly axillary,
followed by cervical or mediastinal nodes) or less
commonly from the pleura or chest wall or via the
haematogenous route. Primary TB of the breast is
rare. In some cases tubercular mastitis may be
mistaken for breast carcinoma.

 Necrotising granulomas are the

histopathological hallmark of TB
infection. In idiopathic
granulomatous mastitis, nonnecrotising granulomatous
inflammation is centred on lobules
that clinically may result in a painless
mass.