Differentials
Breast engorgement
SIGNS / SYMPTOMS
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., breast-feeding).
INVESTIGATIONS
Usually becomes clinically apparent as breast-feeding continues.
Nipple sensitivity
SIGNS / SYMPTOMS
There is usually no evidence of nipple trauma, features of breast inflammation, or fever.
Nipple vasospasm (Raynaud phenomenon) may manifest with nipple pain.
Nipple sensitivity with breast-feeding usually subsides once suckling begins, whereas pain from trauma or infection persists or increases.
INVESTIGATIONS
Usually becomes clinically apparent as breast-feeding continues.
Galactocele
SIGNS / SYMPTOMS
A milk retention cyst may cause a tender palpable breast lump, but there are usually no sharp shooting pains and no signs of breast inflammation or systemic illness.
INVESTIGATIONS
A galactocele appears on ultrasound as a well-defined lesion with a thin echogenic wall, which may contain coarse calcification. A breast abscess may also be well circumscribed, macrolobulated, irregular, or ill defined with possible septae.
Galactocele aspiration yields nonpurulent milk.
Fibrocystic breasts
SIGNS / SYMPTOMS
Painful breast tissue before menses improves during menstruation.
Lumps are palpated mainly in the upper outer quadrant.
A nonbloody nipple discharge may be reported.
INVESTIGATIONS
Ultrasound may help diagnose benign cystic breast tissue.
Mammography is only indicated to help with diagnosis of fibrocystic disease in older women, not adolescents, because the density of breast tissue in adolescents makes interpretation difficult.
Mastodynia
SIGNS / SYMPTOMS
Mastalgia may be cyclic or noncyclic with menstruation.
There should be no symptoms or signs of breast inflammation.
INVESTIGATIONS
Specific tests are not indicated.
Diagnosis is based on history and examination.
Breast trauma
SIGNS / SYMPTOMS
Trauma may cause fat necrosis, which could manifest as a breast mass.
Signs of inflammation are uncommon.
INVESTIGATIONS
Imaging studies may mimic carcinoma (as also occurs on occasion with breast infection).
A biopsy may be indicated for a definitive diagnosis.
Primary invasive breast cancer
SIGNS / SYMPTOMS
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. Paget disease will involve the nipple.
Inflammatory breast cancer may resemble mastitis with breast enlargement, warmth, tenderness, edema, erythema, and possible skin discoloration.
INVESTIGATIONS
Imaging studies, such as mammography, may reveal a mass, increased density, and microcalcification.
Percutaneous biopsy (recommended method), or surgical excision (excisional biopsy) if indicated, is necessary to establish the diagnosis.
A skin-punch biopsy for inflammatory breast carcinoma will show tumor infiltration of dermal lymphatics.
Fibroadenoma
SIGNS / SYMPTOMS
Presents typically as a nontender, rubbery, well-circumscribed, and mobile mass.
INVESTIGATIONS
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.
Fat necrosis
SIGNS / SYMPTOMS
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.
INVESTIGATIONS
Breast imaging findings may not be specific.
A breast biopsy is the most accurate means of providing a definitive diagnosis.
Diabetes
SIGNS / SYMPTOMS
May manifest with one or more hard, irregular, mobile, discrete, painless, palpable masses.
Complications arising from diabetes such as retinopathy, neuropathy, and nephropathy may be present.
Breast lesions tend to be recurrent and bilateral.
Patients may have other autoimmune diseases.
INVESTIGATIONS
Breast imaging studies may be nonspecific and can mimic cancer.
Biopsy shows sclerosing lobular lymphocytic mastitis.
Mondor disease
SIGNS / SYMPTOMS
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.
INVESTIGATIONS
Mammography and a microbiology workup are usually negative.
Systemic lupus erythematosus
SIGNS / SYMPTOMS
There may be a tender mass lesion with possible skin changes.
Chronic mastitis with flares may be reported.
INVESTIGATIONS
Serologic evidence of lupus is usually present.
Mammography may show architectural distortion, fat necrosis, or calcifications.[39]
A biopsy may help, showing lupus panniculitis.
Necrotizing fasciitis
SIGNS / SYMPTOMS
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.
Examination by an experienced surgeon is critical.
A history of prior trauma, skin biopsy, or a surgical wound in the mammary region may be reported.
INVESTIGATIONS
Laboratory tests may show leukocytosis, elevated BUN, and reduced serum sodium level.
Infection can be diagnosed with rapid streptococcal diagnostic kits, if available.
Microbiology studies and excisional deep skin biopsy may be helpful in diagnosing and identifying the causative organisms and confirming the diagnosis.
Hidradenitis suppurativa
SIGNS / SYMPTOMS
Presents mainly around hair follicles in the axilla and intertriginous regions under the breasts.
Lesions range from comedones to painful lumps, abscesses, and skin scarring, and these may be associated with a purulent discharge.
INVESTIGATIONS
A biopsy will show acute and chronic folliculitis with a possible foreign body giant cell inflammation.
Costochondritis
SIGNS / SYMPTOMS
There is localized sternal pain, often exacerbated with respiration or activity.
Pain may radiate.
A palpable swelling with redness is often located about 4 cm from the sternal edge.
A breast examination is usually unremarkable.
INVESTIGATIONS
Tests are not necessary.
Gigantomastia
SIGNS / SYMPTOMS
Massive hypertrophy of the breasts may occur early in pregnancy.
There may be associated skin necrosis.
INVESTIGATIONS
Microbiology studies may be required to exclude underlying infection.
Impetigo
SIGNS / SYMPTOMS
Features of impetigo including vesicles/bullae and crusting.
INVESTIGATIONS
Usually clinical diagnosis.
Furuncle
SIGNS / SYMPTOMS
Painful, tender, red swollen area that becomes cystic; may be accompanied by malaise or fever.
INVESTIGATIONS
Usually clinical diagnosis.
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