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Bloody nipple discharge in infants
ARTICLE IN PRESS The Breast (2006) 15, 253–254
THE BREAST www.elsevier.com/locate/breast
CASE REPORT
Bloody nipple discharge in infants A.T. George, P.K. Donnelly The Breast Clinic, Torbay District General Hospital, Torquay, South Devon TQ2 7AA, UK Received 23 February 2005; accepted 26 May 2005
KEYWORDS Bloody nipple discharge; Infants
Summary Though milky nipple discharge is frequently seen in neonates, blood stained discharge from the nipple is an exceptionally rare phenomenon. We noted a case of a three-month-old baby girl who presented with bilateral blood stained nipple discharge without signs of inflammation; engorgement or hypertrophy and which subsided without any intervention. This case is reported along with literature review about managing this rare condition. & 2005 Elsevier Ltd. All rights reserved.
Case report A healthy three-month-old baby girl presented with bilateral bloody nipple discharge of 2 weeks duration. The infant had been entirely formula fed and her mother had received no medications during pregnancy. There was no history of drug ingestion and trauma to the breasts was denied. Past history was unremarkable. Family background revealed no history of breast carcinoma. On examination, both breasts were normal without any signs of inflammation, engorgement or hypertrophy. A drop of discoloured blood was apparent on both nipples. Rest of the physical examination yielded unremarkable findings. Cytology was benign and culture of the discharge was negative for bacteria. No active treatment was initiated except for regular follow-ups. The left nipple ceased to Corresponding author.
E-mail address: [email protected] (A.T. George).
discharge after 1 month while the right one (Fig. 1) continued for 7 months after which it resolved spontaneously.
Discussion While physiological enlargement of the breast and milky discharge in neonates is known to reflect placentally transmitted maternal and foetal hormones,1 a bloody discharge in infancy appears to be extremely rare.2 Berkowitz and Inkless3 first reported this unusual phenomenon in two neonates attributing it to ductal hyperplasia caused by hormonal stimulation but failed to identify the underlying pathological cause. Stringel et al.4 for the first time followed by Miller et al.5 suggested mammary duct ectasia as an underlying cause, based on specimen histology. Mammary duct ectasia—proposed by Haagensen6—describes a benign transformation consisting of dilatation of the mammary duct, periductal fibrosis and
0960-9776/$ - see front matter & 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.breast.2005.05.004
ARTICLE IN PRESS 254
A.T. George, P.K. Donnelly high risk of breast deformity, especially in girls— where a selective excision of the discharging duct may be opted for, instead of a major duct excision12 to ensure ability to breast-feed in the future. Spontaneous resolution of the discharge being a rule rather than an exception in all the reported cases and in the light of malignancy being extremely rare in this age group, an expectant line of management would be appropriate –however, in a case of persistent unilateral bloody discharge with a palpable mass or suspicious investigative reports, the breast may need to be biopsied or excised in order to avoid missing an underlying malignancy. Figure 1 Discharge from the right nipple.
inflammation—the presence or absence of masses being determined by the degree of ectasia. Dilated ducts and hyperplastic epithelium are features of subareolar breast nodules characteristically seen in full term infants.7 These nodules, which are the precursors from which adult breasts develop, may persist into the second year of life before they regress. Bacterial infections causing bloody nipple discharge have been reported8,9 but in this case, neither the bacterial culture from the nipple secretion nor the clinical or histological findings suggested an infective pathology. Though a major fear is that of an underlying carcinoma in a case of bloody nipple discharge, they are exceptionally rare—but reported10,11— presenting as unilateral gradually enlarging masses. Benign discharge is in general, bilateral and intermittent with no underlying masses. Thus, differences in viewing and managing unilateral and bilateral bloody nipple discharges. In published reports, bloody nipple discharges are reported lasting from 2 weeks to 9 months. Surgical intervention for discharges for longer periods should be considered carefully due to the
References 1. Weimann E. Clinical management of nipple discharge in neonates and children. J Paediatr Child Health 2003;39: 155–6. 2. McKiernan J, Coyne J, Cahalane S. Histology of breast development in early life. Arch Dis Child 1988;63:136–9. 3. Berkowitz CD, Inkelis SH. Bloody nipple discharge in infancy. J Pediatr 1983;103:755–6. 4. Stringel G, Perelman A, Jiminez C. Infantile mammary duct ectasia: a cause of bloody nipple discharge. J Pediatr Surg 1986;21:671–4. 5. Miller JD, Brownell MD, Shaw A. Bilateral breast masses and bloody nipple discharge in a 4-year-old boy. J Pediatr 1990;116:744–7. 6. Haagensen CD. Mammary duct ectasia. A disease that may simulate carcinoma. Cancer 1951:749–61. 7. Dehner LP. Pediatric surgical pathology, 2nd ed. Baltimore: Williams & Wilkins; 1987. p. 104–19. 8. Bundred NJ, Dixon JM, Lumsden AB, et al. Are the lesions of duct ectasia sterile? Br J Surg 1985;72:844–5. 9. Aitken RJ, Hood J, Going JJ, et al. Bacteriology of mammary duct ectasia. Br J Surg 1988;75:1040–1. 10. Karl SR, Ballantine TVN, Zaino R. Juvenile secretory carcinoma of the breast. Ann Surg 1985;20:368–71. 11. Martino A, Zamparelli M, et al. Unusual clinical presentation of a rare case of phylloides tumour of the breast in an adolescent girl. J Pediatr Surg 2001;36:941–3. 12. King TA, Cater KM, Bolton JS, Fuhrman GM. A simple approach to nipple discharge. Ann Surg 2000;55:960–5.
THE BREAST www.elsevier.com/locate/breast
CASE REPORT
Bloody nipple discharge in infants A.T. George, P.K. Donnelly The Breast Clinic, Torbay District General Hospital, Torquay, South Devon TQ2 7AA, UK Received 23 February 2005; accepted 26 May 2005
KEYWORDS Bloody nipple discharge; Infants
Summary Though milky nipple discharge is frequently seen in neonates, blood stained discharge from the nipple is an exceptionally rare phenomenon. We noted a case of a three-month-old baby girl who presented with bilateral blood stained nipple discharge without signs of inflammation; engorgement or hypertrophy and which subsided without any intervention. This case is reported along with literature review about managing this rare condition. & 2005 Elsevier Ltd. All rights reserved.
Case report A healthy three-month-old baby girl presented with bilateral bloody nipple discharge of 2 weeks duration. The infant had been entirely formula fed and her mother had received no medications during pregnancy. There was no history of drug ingestion and trauma to the breasts was denied. Past history was unremarkable. Family background revealed no history of breast carcinoma. On examination, both breasts were normal without any signs of inflammation, engorgement or hypertrophy. A drop of discoloured blood was apparent on both nipples. Rest of the physical examination yielded unremarkable findings. Cytology was benign and culture of the discharge was negative for bacteria. No active treatment was initiated except for regular follow-ups. The left nipple ceased to Corresponding author.
E-mail address: [email protected] (A.T. George).
discharge after 1 month while the right one (Fig. 1) continued for 7 months after which it resolved spontaneously.
Discussion While physiological enlargement of the breast and milky discharge in neonates is known to reflect placentally transmitted maternal and foetal hormones,1 a bloody discharge in infancy appears to be extremely rare.2 Berkowitz and Inkless3 first reported this unusual phenomenon in two neonates attributing it to ductal hyperplasia caused by hormonal stimulation but failed to identify the underlying pathological cause. Stringel et al.4 for the first time followed by Miller et al.5 suggested mammary duct ectasia as an underlying cause, based on specimen histology. Mammary duct ectasia—proposed by Haagensen6—describes a benign transformation consisting of dilatation of the mammary duct, periductal fibrosis and
0960-9776/$ - see front matter & 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.breast.2005.05.004
ARTICLE IN PRESS 254
A.T. George, P.K. Donnelly high risk of breast deformity, especially in girls— where a selective excision of the discharging duct may be opted for, instead of a major duct excision12 to ensure ability to breast-feed in the future. Spontaneous resolution of the discharge being a rule rather than an exception in all the reported cases and in the light of malignancy being extremely rare in this age group, an expectant line of management would be appropriate –however, in a case of persistent unilateral bloody discharge with a palpable mass or suspicious investigative reports, the breast may need to be biopsied or excised in order to avoid missing an underlying malignancy. Figure 1 Discharge from the right nipple.
inflammation—the presence or absence of masses being determined by the degree of ectasia. Dilated ducts and hyperplastic epithelium are features of subareolar breast nodules characteristically seen in full term infants.7 These nodules, which are the precursors from which adult breasts develop, may persist into the second year of life before they regress. Bacterial infections causing bloody nipple discharge have been reported8,9 but in this case, neither the bacterial culture from the nipple secretion nor the clinical or histological findings suggested an infective pathology. Though a major fear is that of an underlying carcinoma in a case of bloody nipple discharge, they are exceptionally rare—but reported10,11— presenting as unilateral gradually enlarging masses. Benign discharge is in general, bilateral and intermittent with no underlying masses. Thus, differences in viewing and managing unilateral and bilateral bloody nipple discharges. In published reports, bloody nipple discharges are reported lasting from 2 weeks to 9 months. Surgical intervention for discharges for longer periods should be considered carefully due to the
References 1. Weimann E. Clinical management of nipple discharge in neonates and children. J Paediatr Child Health 2003;39: 155–6. 2. McKiernan J, Coyne J, Cahalane S. Histology of breast development in early life. Arch Dis Child 1988;63:136–9. 3. Berkowitz CD, Inkelis SH. Bloody nipple discharge in infancy. J Pediatr 1983;103:755–6. 4. Stringel G, Perelman A, Jiminez C. Infantile mammary duct ectasia: a cause of bloody nipple discharge. J Pediatr Surg 1986;21:671–4. 5. Miller JD, Brownell MD, Shaw A. Bilateral breast masses and bloody nipple discharge in a 4-year-old boy. J Pediatr 1990;116:744–7. 6. Haagensen CD. Mammary duct ectasia. A disease that may simulate carcinoma. Cancer 1951:749–61. 7. Dehner LP. Pediatric surgical pathology, 2nd ed. Baltimore: Williams & Wilkins; 1987. p. 104–19. 8. Bundred NJ, Dixon JM, Lumsden AB, et al. Are the lesions of duct ectasia sterile? Br J Surg 1985;72:844–5. 9. Aitken RJ, Hood J, Going JJ, et al. Bacteriology of mammary duct ectasia. Br J Surg 1988;75:1040–1. 10. Karl SR, Ballantine TVN, Zaino R. Juvenile secretory carcinoma of the breast. Ann Surg 1985;20:368–71. 11. Martino A, Zamparelli M, et al. Unusual clinical presentation of a rare case of phylloides tumour of the breast in an adolescent girl. J Pediatr Surg 2001;36:941–3. 12. King TA, Cater KM, Bolton JS, Fuhrman GM. A simple approach to nipple discharge. Ann Surg 2000;55:960–5.