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JURNAL ABSCESS OF THE BREAST



Horizontal Scroll: Nama : Ifa Nur Farida
NIM : 2010.0661.066
 


 ABSES PAYUDARA

I. Definisi
Abses adalah suatu penimbunan nanah, biasanya terjadi akibat suatu infeksi bakteri. Jika bakteri menyusup ke dalam jaringan yang sehat, maka akan terjadi infeksi. Sebagian sel mati dan hancur, meninggalkan rongga yang berisi jaringan dan sel-sel yang terinfeksi. Sel-sel darah putih yang merupakan pertahanan tubuh dalam melawan infeksi, bergerak ke dalam rongga tersebut dan setelah menelan bakteri, sel darah putih akan mati. Sel darah putih inilah yang mengisi rongga tersebut.
Akibat penimbunan nanah ini, maka jaringan disekitarnya akan terdorong. Jaringan pada akhirnya tumbuh di sekeliling abses dan menjadi dinding pembatas abses. Hal ini merupakan mekanisme tubuh untuk mencegah penyebaran infeksi lebih lanjut. Jika suatu abses pecah didalam, maka infeksi bisa menyabar di dalam tubuh maupun dibawah permukaan kulit, tergantung pada lokasi abses.

II.  Etiologi
Infeksi pada payudara biasanya disebabkan oleh bakteri yang umum ditemukan pada kulit normal (staphylococcus aureus). Infeksi terjadi khususnya pada saat ibu menyusui. Bakteri masuk ke tubuh melalui kulit yang rusak, biasanya pada puting susu yang rusak pada masa awal menyusui. Area yang terinfeksi akan terisi dengan nanah.
Infeksi pada payudara tidak berhubungan dengan menyusui harus dibedakan dengan kanker payudara. Pada kasus yang langka, wanita muda sampai usia pertengahan yang tidak menyusui mengalami subareolar abscesses (terjadi dibawah areola, area gelap sekitar puting susu).
Suatu infeksi bakteri bisa menyebabkan abses melalui bebebrapa cara yaitu sebagai berikut :
1.    Bakteri masuk ke bawah kulit akibat luka dari tusukan jarum tidak steril
2.    Bakteri menyebar dari suatu infeksi dibagian tubuh yang lain.
3.    Bakteri yang dalam keadaan normal, hidup di dalam tubuh manusia dan tidak menimbulkan gangguan, kadang bias menyebabkan abses.
Peluang terbentuknya suatu abses akan meningkat jika :
1.  Terdapat kotoran atau benda asing di daerah tempat terjadinya infeksi.
2.    Daerah yang terinfeksi mendapatkan aliran darah yang kurang.
3.    Terdapat gangguan system kekebalan tubuh.
III.  PATOFISIOLOGI
Adapun patogenesis dari abses payudara ini adalah luka atau lesi pada puting sehingga terjadi peradangan kumudian organisme berupa bakteri atau kuman masuk kedalam payudara sehingga  pengeluaran susu terhambat akibat  penyumbatan duktus kemudian terjadi infeksi yang tidak tertangani yang mengakibatkan terjadinya abses.

IV.  GAMBARAN KLINIS
Gejala dari abses tergantung pada lokasi dan pengaruhnya terhadap fungsi suatu organ atau syaraf. Gejala dan tanda yang sering ditimbulkan oleh abses payudara diantaranya :
·         Teraba massa, suatu abses yang terbentuk tepat dibawah kulit biasanya tampak sebagai suatu benjolan. Jika abses akan pecah, maka daerah pusat benjolan akan lebih putih karena kulit diatasnya menipis.
·         Gejala sistematik berupa demam tinggi, menggigil, malaise
·         Nipple discharge (keluar cairan dari putting susu, bisa mengandung nanah)
·         Gatal- gatal
·         Pembesaran kelenjar getah bening ketiak pada sisi yang sama dengan payudara yang terkena.
Menurut Sarwono (2009), pada abses payudara memiliki tanda dan gejala yaitu:
·          Nyeri payudara yang berkembang selama periode laktasi
·         Fisura putting susu
·         Fluktuasi dapat dipalpasi atau edema keras
·         Warna kemerahan pada seluruh payudara atau lokal
·         Limfadenopati aksilaris yang nyeri
·         Pembengkakan yang disertai teraba cairan dibawah kulit
·         Suhu badan meningkat dan menggigil
·         Payudara membesar, keras da akhirnya pecah dengan borok serta keluarnya cairan nanah bercampur air susu serta darah.
(Ilmu Kebidanan, Penyakit Kandungan dan Keluarga Berencana ; 317)

V  PENANGANAN
a.     Teknik menyusui yang benar.
b.    Kompres payudara dengan air hangat dan air dingin secara bergantian.
c.    Meskipun dalam keadaan mastitis, harus sering menyusui bayinya.
d.     Mulailah menyusui pada payudara yang sehat.
e.     Hentikan menyusui pada payudara yang mengalami abses, tetapi ASI harus tetap dikeluarkan.
f.       Apabila abses bertambah parah dan mengeluarkan nanah, berikan antibiotik.
g.     Rujuk apabila keadaan tidak membaik.















Horizontal Scroll: Nama : Ifa Nur Farida
NIM : 2010.0661.066
 

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3307088/
Primary tubercular abscess of the breast – an unusual entity
R Gupta,* RP Singal,** A Gupta,*** S Singal,**** SR Shahi,***** and R Singal******
Abstract
Primary breast tuberculosis manifested as abscess is a rare entity. We are reporting a case of primary breast tuberculosis, which presented as breast abscess. Abscess was drained and tissue sent for histopathology. To our surprise, diagnosis came as breast tuberculosis. Aspiration cytology was not done, as it is not a routine test for abscess cases. Patient was put on anti- tubercular drugs. In the follow-up of 6 months, she was asymptomatic and advised to continue medicine.
Keywords: Extra – pulmonary, lump, tuberculosis, managementz
Introduction
Breast tuberculosis (TB) is a rare form of extra pulmonary TB which was first described by Sir Astley Cooper [1]. Although worldwide, over one billion people suffer from TB, mammary tuberculosis is an extremely rare condition. Its primary form is even more infrequent. The incidence of isolated TB of the breast ranges from 0.10% to 0.52% is scarcely reported even in countries with a high incidence of tuberculosis infection [2]. This is explained by a noticeable resistance of the mammary tissue to the mycobacterium tuberculosis [3].
Case report
A 42-year-old female reported with pain in the right breast for two months, along with off and on fever. She started feeling heaviness in her right breast 20 days before. There were no other complaints. Patient took treatment from the local practioner but there was no relief.
On examination of the right breast, local temperature was raised and a tender lump of about 4x6 cm was felt in the upper outer quadrant. Lump was firm in consistency and non-mobile. Signs of inflammation were present. Provisional diagnosis was made as breast abscess.
Total leukocyte counts and erythrocyte sedimentation rate was raised. Rests of blood tests were within normal limits including chest X-ray. Ultrasonography of the breast revealed a large homogeneous capacity in right breast with area of asymmetrical density (Fig. 1).
Fig. 1
Ultrasonography of breast showed hypoechoic lesion with multiple internal echoes
On needle aspiration, thick pus came out. Incision given and thick pus was drained out of about 100 ml. Tissue and pus was sent for histopathology and, to our surprise, the diagnosis came as breast tuberculosis (Fig. 2).
Fig. 2
Photomicrograph showing caseating granuloma in the breast (H & E, X – 200)
The patient was put on anti-tubercular drugs (rifampicin 600 mg, isoniazid 300 mg, pyrazinamide 1500 mg and ethambutol 1000 mg per day) for 2 months and continued with the addition of rifampicin and isoniazid therapy for 4 additional months. In the follow-up period of 6 months, the patient recovered very well and was advised to continue the treatment
Discussion
Isolated TB breast is an uncommon condition, even in developing countries where pulmonary and other forms of extrapulmonary manifestations of TB are endemic. The incidence of isolated TB of the breast remains low, ranging from 0.10% to 0.52%. In the high tubercular endemic countries like India, the incidence represents 3 to 4.5% of the mammary pathologies [4]. In the Western countries, with a lower tubercular incidence, it represents less than 0.1% of the mammary lesions examined via histology [3,5]. TB of the breast usually affects women aged between 20 and 50 years. Breast involvement can be either primary without any extra-mammary focus, or secondary to pulmonary tuberculosis. The primary form of the disease is rare [6].
Breast tissue, along with skeletal muscle and spleen, appears to be relatively resistant to tuberculous infection [7]. The commonest location of the lump in breast is the central or upper outer quadrant of the breast [8]. The mass may be fluctuant and is usually covered with indurated tissue. It is usually fixed to the skin and fistulization is not uncommon. Nipple and skin retraction can also occur, but breast discharge and pain are not common [9].
It may be classified into three types, namely: nodular, disseminated and sclerosing varieties. McKeown and Wilkinson classified tuberculosis of the breast into five different types: the three stated above and acute miliary tuberculosis mastitis and tuberculosis mastitis obliterans [10]. The nodular form is the most common variety and is characterized by a well defined, painless, slow growing caseous lesion in the breast. Involvement of overlying tissue is usually late and it is at this point that the mass becomes painful. As in our case, the patient presented with breast abscess, and, on histology diagnosis, it came as tuberculosis, which is very rare. Ultrasound is useful for characterising the ill-defined densities shown on mammography, by excluding solid masses, but the findings of a hypoechoic lesion with heterogeneous internal echoes and irregular borders are not specific [2].
Microbiological and histological examinations remain the gold standard for the diagnosis of this uncommon disease. Early diagnosis is difficult, as the characteristic sinuses appear late in the course of the disease. Tuberculosis of the breast is often diagnosed as pyogenic abscess in young women and, in the elderly as carcinoma. In our case breast abscess was diagnosed after the drainage and histopathological examination. The treatment of tuberculosis mastitis is best achieved by conservative surgery and anti-tuberculosis chemotherapy.
Conclusion
The diagnosis must be considered in young patients presenting with a palpable lump, especially if they are lactating. A histological examination is required for confirmation. We concluded that if patient presented with an abscess, we should also go for aspiration cytology keeping in mind that the treatment will be easy. It is always a must to do tissue biopsy when the clinical impression is merely breast abscess.
References
1. Cooper Part I. London: Longman, Rees, Orme, Brown, and Green. 1829. Illustrations of the Diseases of the Breast; p. 73.
2. Hale JA, Peters GN, Cheek JH. Tuberculosis of the breast: rare but still extant. Am J Surg. 1985;150:620–624. [PubMed]
3. Tewari M, Shukla HS. Breast tuberculosis: diagnosis, clinical features, and management. Indian J Med Res. 2005;122:103–110. [PubMed]
4. Gupta V, Mohan H, Jain P. Tuberculous mastitis: A report of two cases in elderly females. Jpn J Infect Dis. 2006;59:279–280. [PubMed]
5. Kalac N, Ozkan B, Bayiz H. Brest tuberculosis. Breast. 2002;11:346–349. [PubMed]
6. Zandrino F, Monetti F, Gandolfo N. Primary tuberculosis of the breast. a case report. Acta Radiol. 2000;41:61–63. [PubMed]
7. Alagaratnam TT, Ong GB. Tuberculosis of the breast. Br J Surg. 1980;67:125–126. [PubMed]
8. Morsad F, Ghazli M, Boumzgou K. Mammary tuberculosis: a series of 14 cases. J Gynaecol obstet Biol Reprod. 2001;30:331–337. [PubMed]
9. Green RM, Ormerud LP. Mammary tuberculosis: rare but still present in the united kingsom. Int J Juberc Lung Dis. 2000;4:788–790. [PubMed]
10. McKeown KC, Wilkinson KW. Tuberculosis disease of the breast. Br J Surg. 1952;39:420–429. [PubMed]

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