Mastitis differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Prince Tano Djan, BSc, MBChB [2]

Overview

Mastitis must be differentiated from other diseases that cause breast pain and/or swelling, such as galactocele, breast engorgement , mastodynia, fibrocystic breast disease, breast cancer, fibroadenoma, mondor's disease and breast trauma.

Differentiating Mastitis from other diseases

Mastitis must be differentiated from other diseases that cause breast pain and swelling as shown below:

Breast abscess should be differentiated from other diseases that cause swelling in the breast skin. These diseases are like mastitis, inflammatory breast cancer, galactocele, plugged duct, Mondor's syndrome, fibroadenoma and lipoma.

Diseases	Laboratory Findings		Physical Examination			History and Symptoms								Other Findings
	Breast milk culture	Biopsy	Breast tenderness	Skin induration	Cordlike vein appearance	History of trauma	Nipple retraction	Nipple discharge	Erythema	Fever	Warmth	Lymphadenopathy	Itching
Breast abscess	+ for bacteria	✘	✔	✔	✘	✔	✘	✔	✔	✔	✔	✘	✘
Mastitis	+ for bacteria	✘	✔		✘	✔	✘	✔	✔	✔	✔	✔	✘
Inflammatory breast cancer	✘	✔	✔	✔		✘	✔	✘	✔	✘	✔	✔	✔	*Peau d' orange appearance of the skin *Metastasis is common.
Galactocele	✘	✘	✘	✘		✘	✘	✔	✘	✘	✘	✘	✘	It is differentiated from other masses by US.
Plugged duct	✘	✘	✔	✘		✘	✘	✘	✘	✘	✘	✘	✘
Mondor's syndrome			✔	✔	✔	✘								Retracted breast skin and elevation of the skin may be observed.
Cellulitis	✘		✔	✔					✔	✘	✔	✔	✘
Fibroadenoma	✘	✔	✘	✘		✘		✘	✔					*Peau d' orange skin apperance. *Enlarged veins on the skin

Other differential diagnosis of breast abscess can include: cystosarcoma phyllodes, breast cyst, breast carcinoma, lymphangioma, hemangioma and lipoma

Galactocele

A milk retention cyst may cause a tender palpable breast lump. Galactocele aspiration yields nonpurulent milk.

Breast engorgement

Engorgement usually occurs on the third to fifth postpartum day. There may be bilateral generalized breast pain, firmness, erythema, warmth, and a mild fever (milk fever), but there is usually no edema. Relieved by frequent emptying of the breasts (e.g., breastfeeding).

Nipple sensitivity

There is usually no evidence of nipple trauma, features of breast inflammation, or fever.

Mastodynia

Mastalgia may be cyclic or noncyclic with menstruation. There should be no symptoms or signs of breast inflammation.

Fibrocystic breasts

Painful breast tissue before menses improves during menstruation. Lumps are palpated mainly in the upper outer quadrant. A nonbloody nipple discharge may be reported.

Primary invasive breast cancer

The signs and symptoms of breast cancer may be similar to those of breast infection. It may present as a hard, irregular, painless mass that may or may not be fixed to the underlying tissue. There may be a nipple discharge, nipple or skin retraction, skin edema (peau d'orange) and regional lymphadenopathy.

Fibroadenoma

Presents typically as a nontender, rubbery, well-circumscribed, and mobile mass. Imaging studies, such as breast ultrasound and mammography, generally reveal a solid, homogeneous, well-circumscribed, avascular mass with occasional coarse calcification. Pathologic examination will demonstrate a fibroepithelial lesion.

Breast trauma

Trauma may cause fat necrosis, which could manifest as a breast mass. Signs of inflammation are uncommon.

Fat necrosis

Typically results in a tender, round, firm breast mass. The skin may be dimpled over such a lump. Inflammation is usually not a common feature unless there is an associated infection. A breast biopsy is the most accurate means of providing a definitive diagnosis.

Mondor disease

Thrombophlebitis of a superficial vein may cause breast pain and a cord-like mass with possible skin dimpling, usually in the lower quadrants. The cord is accentuated by traction, elevation of the breast, or abduction of the ipsilateral arm.

Diabetes

May manifest with one or more hard, irregular, mobile, discrete, painless, palpable masses.

Necrotizing fasciitis

Patients may have fever, chills, and extreme pain associated with rapidly advancing skin erythema, and possible cyanosis, vesicles, bullae, ulcers, crepitation, and a black necrotic eschar. A history of prior trauma, skin biopsy, or a surgical wound in the mammary region may be reported.

Hidradenitis suppurativa

Presents mainly around hair follicles in the axilla and intertriginous regions under the breasts.

Costochondritis

There is localized sternal pain, often exacerbated with respiration or activity.

Neonatal breast hypertrophy

Benign breast enlargement may be transient. The breast bud in such cases is not red or tender.

Gigantomastia

Massive hypertrophy of the breasts may occur early in pregnancy.

Impetigo

Features of impetigo including vesicles/bullae and crusting. Usually clinical diagnosis.

Furuncle

Painful, tender, red swollen area that becomes cystic; may be accompanied by malaise or fever. Usually clinical diagnosis.