Deep breast pain during lactation: a case-control study in Sweden investigating the role of Candida albicans

The pathology of canine mammary candidiasis with embolic dissemination in a dog

Candidiasis is a fungal disease caused by Candida albicans or other members of the genus Candida. Descriptions of candidiasis are comparatively reduced in veterinary relative to human medicine, with no cases of mammary candidiasis being identified in pet animals. This report presents the cytological, pathological, and molecular findings of mammary candidiasis with embolic dissemination in a postpartum dog. A 1-year-old, female Shih-tzu dog that had recently given birth was admitted to a veterinary teaching hospital in Southern Brazil after repeated episodes of intermittent mammary disease and a neurological syndrome. The dog was euthanized due to worsened clinical status and poor prognosis despite adequate clinical therapy and was submitted for routine post-mortem evaluation to determine the cause of the neurological manifestations. Cytological analysis of purulent mastitis identified intralesional fungal hyphae. Gross evaluation revealed multiple masses within the kidneys, liver, myocardium, pancreas, and brain. Routine histopathology and histochemistry identified fungal nephritis, hepatitis, myocarditis, pancreatitis, and encephalitis associated with intralesional fungal hyphae, frequently with fungal emboli and vasculitis. Pure cultures of C. albicans were obtained from fragments of the masses observed at the myocardium and kidneys, with the typical germ tube of C. albicans being identified by microscopic evaluation. A PCR assay that targeted the ITS1 and 4 generic regions of fungi, amplified the desired amplicon, and direct sequencing confirmed C. albicans. Immunohistochemical and molecular assays designed to identify common infectious disease pathogens of dogs did not confirm the participation of canine distemper virus, canine parvovirus, or canine adenovirus in the target tissues of this dog. These findings suggest that this dog suffered an initial cutaneous lesion, that probably served as portal of entry to the mammary gland, resulting in mammary candidiasis with subsequent embolic dissemination to multiple organs. This report represent the first description of mammary candidiasis in pet animals and probably one of the few pathological descriptions of mammary candidiasis in domestic animals. In this case, the cause of the fungal infection was probably associated with factors intrinsic to abdominal surgery, pregnancy, and the utilization of antibiotics.

Candida guilliermondii as an agent of postpartum subacute mastitis in Rio de Janeiro, Brazil: Case report

Candida spp. can cause mild-to-severe human infections. Certain species have been described as the etiologic agent of human mastitis, inflammation of the breast tissue. Mastitis affects millions of lactating women and can be a source of disease transmission to the infant. In this work, we report the detection of the unusual etiologic agent of human mastitis, Candida guilliermondii, isolated from the milk of a puerperal woman with subacute mastitis in Rio de Janeiro, Brazil. Species identification was performed by MALDI-TOF MS and genetic sequencing. The patient had a full recovery after antifungal therapy.

Breastfeeding With Infectious Diseases

Aims: Human breast milk remains an important source of protection against infection, inflammation, allergy and long-term metabolic disorders for the breastfed offspring. During cases of ongoing infection, the dilemma faced by both medical health professionals and mothers is the need to balance the risk of continuing versus temporarily or permanently ceasing to breastfeed. The aim of our article is to review existing literature regarding breastfeeding during acute infectious and non-infectious illnesses and to provide feasible evidence-based suggestions which can be implemented by medical practitioners during counselling of breastfeeding mothers.

Method: A literature search was conducted on PubMed (US National Library of Medicine) using various combinations of keywords related to breastfeeding and the various infections. The citations from all selected articles were reviewed for additional studies.

Results: Most ongoing infections are not contraindications for breastfeeding, with the exceptions of Human Immunodeficiency viruses (HIV), Human T-cell lymphotropic virus (HTLV) types 1 and 2. Even with HIV, there is increasing evidence to reassure that with adequate antiretroviral therapy, breastfeeding is likely to be safe. Of particular concern during the COVID-19 pandemic too, current evidence indicates that mothers with COVID-19 infection can safely breastfeed, and therefore initiation and continuation of breastfeeding should continue to protect the health of the babies and mothers.

Conclusion: During this pandemic especially, there is a strong and urgent need to support mothers with acute infections who wish to breastfeed. With better awareness, physicians can play an important role in securing positive experiences for breastfeeding mothers and optimizing infant outcomes.

Recent concepts in fungal involvement in skin and soft tissue infections

As the at-risk population expands and new antifungal resistance patterns develop, it is critical to understand and recognize cutaneous manifestations of old and emerging fungal diseases.

PURPOSE OF REVIEW

The aim of this review is to provide an overview of the most frequent and emerging deep cutaneous fungal infections following either primary inoculation or secondary spread after haematogenous seeding in disseminated infections in different geographical areas.

RECENT FINDINGS

Fungal skin and soft tissue infections (SSTIs) encompass a variety of pathological conditions based on the site of the infection, route of acquisition of the pathogen, epidemiological setting and the virulence of the fungus in relation to the host. The approach to a patient suspected of having a fungal SSTI is complex and usually poses a major diagnostic challenge. The treatment approach should include attempts at immune reconstitution, targeted antifungal therapy and/or aggressive surgical debridement.

SUMMARY

Fungal SSTIs can be an important cause of morbidity and mortality in both immunocompromised and immunocompetent patients and are being reported with increasing frequency worldwide.

Re-thinking benign inflammation of the lactating breast: Classification, prevention, and management

Despite the known benefits of breastfeeding for both infant and mother, clinical support for problems such as benign inflammation of the lactating breast remain a research frontier. Breast pain associated with inflammation is a common reason for premature weaning. Multiple diagnoses are used for benign inflammatory conditions of the lactating breast which lack agreed or evidence-based aetiology, definitions, and treatment. This article is the second in a three-part series. This second review analyses the heterogeneous research literature concerning benign lactation-related breast inflammation from the perspectives of the mechanobiological model and complexity science, to re-think classification, prevention, and management of lactation-related breast inflammation. Benign lactation-related breast inflammation is a spectrum condition, either localized or generalized. Acute benign lactation-related breast inflammation includes engorgement and the commonly used but poorly defined diagnoses of blocked ducts, phlegmon, mammary candidiasis, subacute mastitis, and mastitis. End-stage (non-malignant) lactation-related breast inflammation presents as the active inflammations of abscess, fistula, and septicaemia, and the inactive condition of a galactocoele. The first preventive or management principle of breast inflammation is avoidance of excessively high intra-alveolar and intra-ductal pressures, which prevents strain and rupture of a critical mass of lactocyte tight junctions. This is achieved by frequent and flexible milk removal. The second preventive or management principle is elimination of the mechanical forces which result in high intra-alveolar pressures. This requires elimination of conflicting vectors of force upon the nipple and breast tissue during milk removal; avoidance of focussed external pressure applied to the breast, including avoidance of lump massage or vibration; and avoidance of other prolonged external pressures upon the breast. Three other key preventive or management principles are discussed. Conservative management is expected to be effective for most, once recommendations to massage or vibrate out lumps, which worsen micro-vascular trauma and inflammation, are ceased.

Overdiagnosis and overtreatment of nipple and breast candidiasis: A review of the relationship between diagnoses of mammary candidiasis and Candida albicans in breastfeeding women

BACKGROUND

Breastfeeding mothers commonly experience nipple pain accompanied by radiating, stabbing or constant breast pain between feeds, sometimes associated with pink shiny nipple epithelium and white flakes of skin. Current guidelines diagnose these signs and symptoms as mammary candidiasis and stipulate antifungal medications.

AIM

This study reviews existing research into the relationship between Candida albicans and nipple and breast pain in breastfeeding women who have been diagnosed with mammary candidiasis; whether fluconazole is an effective treatment; and the presence of C. albicans in the human milk microbiome.

METHOD

The author conducted three searches to investigate (a) breastfeeding-related pain and C. albicans; (b) the efficacy of fluconazole in breastfeeding-related pain; and (c) composition of the human milk mycobiome. These findings are critiqued and integrated in a narrative review.

RESULTS

There is little evidence to support the hypothesis that Candida spp, including C. albicans, in maternal milk or on the nipple-areolar complex causes the signs and symptoms popularly diagnosed as mammary candidiasis. There is no evidence that antifungal treatments are any more effective than the passage of time in women with these symptoms. Candida spp including C. albicans are commonly identified in healthy human milk and nipple-areolar complex mycobiomes.

DISCUSSION

Clinical breastfeeding support remains a research frontier. The human milk microbiome, which includes a mycobiome, interacts with the microbiomes of the infant mouth and nipple-areolar complex, including their mycobiomes, to form protective ecosystems. Topical or oral antifungals may disrupt immunoprotective microbial homeostasis. Unnecessary use contributes to the serious global problem of antifungal resistance.

CONCLUSION

Antifungal treatment is rarely indicated and prolonged courses cannot be justified in breastfeeding women experiencing breast and nipple pain. Multiple strategies for stabilizing microbiome feedback loops when nipple and breast pain emerge are required, in order to avoid overtreatment of breastfeeding mothers and their infants with antifungal medications.

Candida and Breastfeeding: A Critical Commentary on the Dilemmas Around Diagnosis, Treatment, and Management

Objective

The etiology of nipple pain in breastfeeding women can be challenging for healthcare professionals. The most common cause of nipple pain or damage in breastfeeding women is poor latch and positioning of the baby at the breast (Duncan, 2015). However, when position and attachment is not identified as the cause, controversy exists as to the etiology of the pain with nipple or breast thrush identified as a probable suspect.

Review

The literature was reviewed to explore the diagnosis and management of thrush in breastfeeding women.

Findings

There is a lack of robust evidence in the literature to support an accurate diagnosis of candida as the cause of nipple and/or deep breast pain in breastfeeding women. Diagnosis and management strategies vary between the USA and Europe.

Conclusion

It is important that clinicians supporting and working with breastfeeding women are aware of the differential diagnosis for both breast and nipple pain, as well as utilize their clinical skills effectively to offer the correct treatment and management to women presenting with candida like symptoms (Amir et al., 2013, Wilson-Clay & Hoover, 2017). Culture and sensitivity of mothers expressed milk may be supportive of a diagnosis; however, analysis of mothers' milk is not without its challenges. Breastfeeding women should not be treated for potential candida infection with a traditional clinical examination alone.