Subareolar breast abscess in males

Abstract

BACKGROUND

Subareolar breast abscess is extremely rare in males. Only a few cases of male breast abscess are reported in the literature till date. The clinical presentation of male breast include pain, periareolar swelling, tenderness and abscess formation.

AIM

To study occurrence of subareolar breast abscess in males.

METHODS

A retrospective study of 11 males from April 2014 to July 2024 is reported who presented with subareolar breast abscess.

RESULTS

Nine cases had uncomplicated and idiopathic abscess, and one has diabetes and another has underlying carcinoma breast. Incision drainage was done in 7 cases and one who has underlying carcinoma was managed by local toilet and antibiotics whereas rest two had needle aspiration for pus and other two had conservative treatment by antibiotics only. Pus culture predominantly yielded growth of Staphylococus.

CONCLUSION

Subareolar breast abscess is rare in males. Incision and drainage is treatment of choice in an uncomplicated cases.

Key Words: Breast; Abscess; Male; Incision drainage; Subareolar breast

Core Tip: Subareolar breast abscess is extremely rare in males. Most of cases are of simple abscess. Male breast is usually unilateral. The site of occurrence of breast abscess is usually outer quadrant of breast. Painful swelling of breast is a common manifestation. The Staphylococcus are main causative agents of male breast abscess. Clinical diagnosis with ultrasound of breast is suffice for diagnosis of male breast abscess. Fine needle aspiration cytology is helpful in diagnosis. Incision and drainage is treatment of choice in an uncomplicated cases.

INTRODUCTION

Breast abscess is extremely rare in males[1]. Subareolar breast abscess is commonly seen in females than males. Male subareolar abscess is a localized infection secondary to ductal obstruction and ductal ectasia with inflammation[2]. The predisposing factors suggested in its etiology are iatrogenic, trauma, nipple piercing, smoking, diabetes mellitus and immunocompromised states[3,4]. Stasis of secretions within the duct, its dilation followed by inflammatory reaction with added infection leading to abscess formation. Subareolar breast abscess is unilateral or bilateral presenting with swelling, pain, erythema or tenderness[5,6]. Although subareolar abscess is rare in males, an associated risk factor should always be looked for. The causative organisms detected in male breast abscess are mainly Staphylococcus[7]. The diagnosis of male breast abscess is clinical. The characteristic inflammatory cutaneous signs and symptoms clinch to the on spot diagnosis. Ultrasonography and fine needle aspiration cytology are useful adjuncts in making diagnosis[8]. The treatment of simple male breast abscess is incision and drainage.

MATERIALS AND METHODS

A 10 year retrospective study with prospectively collected data from April 2014 to July 2024 was conducted to study occurrence of male breast abscess. The medical record of all male patients who had diagnosis of breast abscess were analysed retrospectively from individual participant data files, and detailed clinical features, examination, ultrasound, fine needle aspiration cytology and surgery findings were studied. Pus culture were analyzed in this study. Being retrospective study, does not require ethical committee approval. Informed consent and data use authorization was obtained from the included patients.

RESULTS

Total of 11 cases were diagnosed as a case of male breast abscess from April 2014 to July 2024 (Table 1). Left side involvement was seen in 4 patients whereas rest had on right side involvement (Figure 1). Age range was from 13-66 years (Table 1). Total duration of symptoms ranged from 1-7 days. Amount of pus drained varied from 5 mL to 15 mL. Only one case had axillary lymphadenopathy. Smokers were 4 in this series. Only one case was a diabetic. One case has underlying carcinoma and rest were idiopathic. Retraction of nipple was seen in one case only, one who was having underlying cancer. Mammography and computed tomography scan chest/abdomen was done in one case only, rest had ultrasound only. Fine needle aspiration was done in 8 cases which confirmed abscess only and the infected underlying carcinoma in one case. All incision drainage were done under local anesthesia. Incision drainage were done in 7 cases including one who has recurrence after needle aspiration. Two cases were conservatively managed and two had aspiration simply. All were prescribed amoxyclavunate and the one elderly had linzeolid prescribed who was diabetic. In 7 cases, there was growth of Staphylococcus, one had mixed flora with Escherichia coli predominant growth (breast abscess with underlying ductal cancer), three had no growth of any organisms.

Figure 1 Left side involvement was seen in 4 patients whereas rest had on right side involvement. A: Showing subareolar breast abscess; B: Showing subareoar breast abscess in upper area; C: Small breast abscess in lower outer area; D: Showing large breast abscess; E: Ultrasonography breast showing breast abscess in male; F: Showing foul small pink colored thick pus after incision drainage of breast abscess; G: Showing pus coming after incision drainage.

Table 1 Total of 11 cases were diagnosed as a case of male breast abscess from April 2014 to July 2024.

Age	Duration of symptoms	Etiology	Presentation	Size	Location of swelling	Investigation	Treatment
26	7	Idiopathic	Painful swelling	2.7 cm × 1.5 cm	Right, upper outer quadrant, periareolar area	Ultrasound/FNAC	Incision drainage
37	5	Idiopathic	Painful swelling	2 cm × 1.9 cm	Right, outer quadrant, periareolar area	Ultrasound/FNAC	Incision drainage
52	6	Underlying ductal carcinoma	Painful swelling	3 cm × 3 cm	Left, upper inner quadrant, periareolar area	Ultrasound/FNAC/CTScan	Local toilet with neoadjuvant chemotherapy
31	4	Idiopathic	Painful swelling	2.8 cm × 1 cm	Left outer upper quadrant, periareolar area	Ultrasound/FNAC	Aspiration
21	7	Idiopathic	Painful swelling	1.8 cm × 0.9 cm	Left, outer lower quadrant, periareolar area	Ultrasound/FNAC	Aspiration, with recurrence involving incision drainage and excision of involved duct
13	1	Idiopathic	Painful swelling	1 cm × 0.4 cm	Right, upper outer quadrant periareolar area	Ultrasound/FNAC	Conservatively
31	7	Idiopathic	Painful swelling	0.8 cm × 1 cm	Right outer upper quadrant periareolar area	Ultrasound	Conservatively
66	2	Diabetes	Painful swelling	3.7 cm × 1.8 cm	Right outer upper quadrant periareolar area	Ultrasound/FNAC	Incision drainage
22	3	Idiopathic	Painful swelling	1 cm × 1 cm	Left, outer quadrant periareolar area	Ultrasound	Incision drainage
19	4	Idiopathic	Painful swelling	1.7 cm × 1.1 cm	Right upper outer quadrant periareolar area	Ultrasound	Incision drainage
46	4	Idiopathic	Painful swelling	1.6 cm × 1 cm	Right upper and central quadrant periareolar area	Ultrasound/FNAC	Incision drainage

FNAC: Fine needle aspiration cytology.

Recurrence was seen in one case who had aspiration initially, incision drainage with excision of involved duct one in final surgery.

DISCUSSION

A myriad of benign conditions is reported to occur in the male breast. These encompass gynecomastia, intramammary lymph node, sebaceous cyst, diabetic mastitis, hematoma, fat necrosis, and subareolar abscess[9]. The inflammatory lesion of male breast comprises of around 2% of cases[10]. A subareolar breast abscess is an infected lesion that occurs in the subareolar area. In 1951, Zuska et al[11] first reported occurrence of subareolar breast abscess, which is also known as Zuska’s disease. Male breast abscess is mostly located at the subareolar area, and the etiology is obscure. The normal male breast consists predominantly of fat, and contains few secretory ducts, scanty lobules which limits rapid spread and large abscess formation unlike in females. The suggested hypothesis for predisposition for the subareolar location of male breast abscess is that it arises from underlying fat or gynecomastia, usually prominent at the subareolar area. The nipple is considered to be the primary site of inoculation for causative organism[12]. Smoking, diabetes mellitus, obesity, human immunodeficiency virus, nipple piercing, or nipple inversion has been suggested as a risk factor for subareolar breast abscess[13-15]. Rarely, Salmonella infection, Pseudomonas, Actinomycosis, Mobiluncus curtisii, Finegoldia magna, Propionibacterium avidum, tuberculosis, larvae of Musca domestica (common house fly) have been implicated in causation of mastitis in males[16-20]. Majority of cases are uncomplicated.

The pathogenesis is believed to be of squamous metaplasia of normally occurring columnar epithelium of the secretory ducts. This ultimately progresses to abscess formation following rupture of the duct into the surrounding breast tissue. Sequence of gross changes observed was that there was initial localized cellulitis, followed by formation of localized collection usually in outer quadrant side with circumareolar spread from outer quadrant in periareolar area. Resolution occurs in circumferential mode in opposite direction with initial point resolving at the end.

The clinical manifestations are painful swelling, redness, tenderness, nipple retraction, and nipple discharge. Fever is not much reported[5]. Most cases of subareolar breast abscess are unilateral, but rare cases can be bilateral also[6]. All cases in this study were unilateral. The history of nipple discharge may or may not be elicited. In this series, there was no discharge of nipple in any case. Rarely, breast abscess in a male may mimic breast cancer[21].

On imaging, male breast abscess has appearance mimicking of female breast abscess. This acute breast abscess is very difficult to be differentiated from malignancy due to pathological changes in abscess. The presence of skin and trabecular thickening in subareolar breast abscess distinguish this from gynecomastia[9]. Ultrasonography-guided core needle biopsy may be performed, and reveal inflammatory cells. In one of case, there was underlying malignancy with secondary infection, mimicking breast abscess diagnosed by fine needle aspiration cytology. This is same as in our case where infected malignant lesion mimicking breast abscess. Ultrasonography findings in male breast abscess include subareolar hypoechoic lesions, distended thickened lymphatic vessels skin and trabecular thickening[22,23]. Breast abscesses typically demonstrating a thick echogenic rim and increased vascularity is suggesting of malignancy. On Doppler ultrasound of male breast abscess, there is presence of irregular, heterogeneous mass having enhanced peripheral vascular flow with lack of vascularity in the fluid collection.

Mammographic findings are variable in male breast abscess. On mammography, male breast abscess shows a subareolar ill-defined mass density with or without calcifications[24]. Skin thickening, a retroareolar mass, or sinus tract formation is characterized on mammography as a dense tracts connecting a breast density to the skin. In advanced cases, there may be fibrosis and architectural distortion of the breast tissue. Eccentric location to the nipple can be a differential diagnostic point for the male breast cancer without microcalcifications. Focal or diffuse asymmetry and even normal looking breast is sometimes visible on mammography. Magnetic resonance imaging has high accuracy in differentiating between patients with mastitis and those with inflammatory breast cancer[25].

Treatment for simple subareolar male breast abscess is incision and drainage. Repeated aspiration under cover of antibiotics with follow-up until complete resolution is treatment available, who refuse incision drainage[26]. Needle aspiration is employed in cases of small abscesses. Two cases had only single aspiration as very size of abscesss being small, reporting just at time of fluctuation development. Conservative management is done for cases who refuse aspiration or incision drainage or report and report at the time of solely initial cellulitis.

Surgical excision of involved duct is done in case of recurrences after repeated aspiration[27,28]. Zuska et al[11] found several major microscopic findings, including acute and chronic inflammation of the lactiferous duct, dilatation of the duct, stasis, and desquamated keratinized epithelium in the duct lumen. Smear shows dense acute inflammatory exudate along with sheets of anucleated squamous in a background of dense acute inflammation. Very rarely, recurrent male breast has been reported in literature and deems removal of underlying focus.

CONCLUSION

Male breast abscess is rare to occur. Most of cases are uncomplicated and usually occur in the outer quadrant. Incision drainage is treatment of choice in uncomplicated cases.