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.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3307088/
Primary tubercular abscess of
the breast – an unusual entity
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).
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).
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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