Recurrent infected galactocele with milk fistula: A rare entity with challenging management

INTRODUCTION

Galactoceles are benign palpable masses containing protein, fat, and lactose and are predominantly identified after breastfeeding cessation, during lactation, or in the third trimester of pregnancy. They occasionally become infected and are frequently associated with inflammation and fat necrosis, which occur when milk leaks into the breast tissue.^[1] Thus, galactoceles are thought to originate from fibrosis caused by an inflammatory response to lactiferous duct dilation and leakage.

Treating infected galactoceles is challenging because drainage poses a risk of milk fistula development and undesirable cosmetic results. If not emptied, the infection may progress into a breast abscess.^[2] Herein, we present a case of a recurrent infected galactocele complicated by a milk fistula, which was eventually managed successfully.

CASE REPORT

A 32-year-old 2-month postpartum lactating woman presented to the surgery clinic with a painful swelling in the left breast, persisting for 3 weeks. She was first treated at another clinic with a mini-incision under local anesthesia; she was prescribed amoxicillin and clavulanate potassium, with no significant improvement. Symptoms included fever, sweating, anorexia, and nausea. She did not have any of the following characteristics: Nipple changes, right breast symptoms, symptoms suggestive of distant metastases, a family history of breast cancer, or a record of current drug use.

Vital signs included: Blood pressure, 110/80 mmHg; heart rate, 100 bpm; and temperature, 37.6°C. Left breast examination revealed a tender 9 × 8 cm mass, with erythema and induration of the overlying skin, but no discharge. The fluctuation sign was positive, and a tender, mobile left axillary lymph node was palpable. The 2-cm transverse wound from the previous treatment was approximately 4 cm from the nipple in the upper outer quadrant.

Laboratory testing included: Leukocyte count, 13.2 × 10⁹/L; hemoglobin, 14.4 g/dL; platelet count, 435×10⁹/L; random blood glucose, 89 mg/dL; Na 136 mmol/L; K 4 mmol/L; creatinine 0.71 mg/dL; and INR 0.9 seconds. Left breast ultrasonography revealed a 10 × 8.5 × 7.5 cm multilobulated hypoechoic collection with mobile internal echoes, extending to all quadrants except the upper inner region, without vascularity. Several enlarged axillary lymph nodes with preserved central echogenic hilum were observed [Figure 1].

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Figure 1:

Ultrasound image of the left breast showing multilobulated hypoechoic collection.

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A substantial quantity of thick, foul-smelling milk was drained by extending the prior incision 1 cm laterally. A culture swab showed no growth. The abscess cavity included all quadrants except the upper inner region, and all septa were excised. Irrigation and suction were performed, and the wound was packed.

The postoperative course was uneventful, and the patient was discharged with daily dressings, oral amoxicillin and clavulanate potassium 1 g twice daily for 5 days, and cabergoline for milk cessation. Breastfeeding cessation was advised to facilitate wound healing. At follow-up, a milk fistula was detected. Five days post-discharge, the patient developed a 4 × 4 cm mass with tenderness, fluctuation, and erythema; ultrasonography confirmed a 3 × 3 cm abscess in the left upper inner quadrant.

A 2-cm radial incision at the 9 o’clock position was performed, draining thick contaminated milk; a culture swab was collected for sensitivity testing [Figure 2]. The postoperative course was unremarkable, and the patient was discharged; cabergoline was continued for milk cessation. At follow-up, milk had accumulated in both wounds. Swabbing revealed ciprofloxacin-sensitive Escherichia coli; consequently, ciprofloxacin 500 mg and clindamycin 300 mg were initiated twice daily for 5 days. The patient received regular dressing changes, and the milk fistula progressively recovered. Subsequently, both wounds exuded minimal greenish discharge, and swabbing revealed Klebsiella pneumoniae. However, the wound had acceptable granulation tissue with no erythema or discomfort. Following discussions with the infectious disease team, we proceeded with observation without further antibiotic treatment.

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Figure 2:

Both wounds can be seen at the upper outer quadrant and 9 o’clock positions.

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Following a protracted healing phase, debridement and swabbing were performed under general anesthesia. Culture findings indicated ciprofloxacin-sensitive Enterobacter cloacae and sulfamethoxazole/trimethoprim-sensitive Staphylococcus haemolyticus. Consequently, ciprofloxacin 500 mg twice daily and sulfamethoxazole/trimethoprim 800/160 mg once daily were prescribed for 7 days.

The patient showed satisfactory progress for 2 weeks. Subsequently, both wounds exuded greenish discharge without signs of inflammation. Culture results revealed methicillin-resistant Staphylococcus aureus. Debridement and negative wound pressure therapy were performed [Figure 3], and sulfamethoxazole/trimethoprim 960 mg twice daily was prescribed for 5 days. At follow-up, the patient showed improvement. An Exufiber (gelling fiber) dressing was applied for several days, followed by collagen foam, ultimately resulting in significant improvement and wound closure [Figure 4].

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Figure 3:

The vacuum-assisted closure (VAC) machine performing negative wound pressure therapy on the upper outer wound.

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Figure 4:

Both wounds after healing.

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DISCUSSION

Managing infected galactoceles is challenging and requires immediate intervention. This report presents the successful treatment of a recurring infected galactocele with a milk fistula.

Small galactoceles may spontaneously dissolve; nonetheless, once apparent, they often continue to expand, as in the present case. Unlike simple cysts, galactoceles contain breast milk and develop into loculations. Aspiration of stagnant milk is challenging, and the cavities frequently refill. Further, aspiration fails to allow decompression of adjacent tissue edema, which is essential for preventing re-accumulation.^[3]

Draining infected galactoceles carries a significant risk of milk fistula formation. However, if not emptied, an abscess may develop.^[2] As galactocele aspiration is often inefficient due to the milk’s viscosity, drain insertion has been proposed as the most effective therapeutic strategy,^[3] with repeated aspiration as an alternative. A previous case of infected galactocele was successfully treated with a pigtail catheter and antibiotics;^[2] in another patient, percutaneous catheter drainage was reported.^[2] However, drain insertion was unfavorable for our patient; instead, negative wound pressure therapy, Exufiber dressing, and collagen foam were successfully implemented.

Milk fistula formation is a poorly documented complication. Due to the limited number of reports, the overall formation rate seems low.^[4] Although spontaneous cases have been reported,^[5] milk fistulas are predominantly associated with surgical procedures and biopsies; consequently, these risks should be addressed before scheduling surgery for breastfeeding women.^[4] If necessary, a fine-needle biopsy is advised to minimize tissue trauma, duct disruption, and fistula development.

Breast abscesses are predominantly caused by S. aureus,^[6] although other pathogens, including methicillin-resistant S. aureus, E. coli, and typhoid, have been documented.^[6,7] In our patient, various pathogens were identified throughout the clinical course. Breast abscess drainage should not be delayed,^[4] and several antibiotics are considered safe while breastfeeding, including dicloxacillin, cephalexin, cefadroxil, and clindamycin. Conversely, ciprofloxacin and tetracycline can transfer into breast milk and are therefore contraindicated.^[4]

CONCLUSION

Our case was complex and challenging. Nonetheless, it was successfully treated with careful management. Moreover, it emphasized the necessity of considering galactocele during management of any breast swelling in a breastfeeding woman and the importance of engaging the obstetricians from the beginning, as simple galactocele can be treated just by suppressing milk production. The present case would significantly enhance the scant literature regarding this rare and unique condition and provide guidance for physicians managing such challenging cases.