This article has Open Peer Review reports available.
A lactating woman presenting with puerperal pneumococcal mastitis: a case report
© Miedzybrodzki and Miller; licensee BioMed Central Ltd. 2013
Received: 25 November 2012
Accepted: 26 March 2013
Published: 25 April 2013
Streptococcus pneumoniae is an uncommon etiologic agent in soft-tissue infections.
We report the case of a 35-year-old Caucasian woman who presented to our facility with puerperal pneumococcal mastitis, and review the only other three cases of pneumococcal mastitis described in the medical literature.
The roles of the various pneumococcal vaccines in preventing this disease are discussed.
Puerperal mastitis occurs most commonly during the first three to six months post-partum in breastfeeding mothers. Up to 25 percent of breastfeeding women have experienced at least one episode of mastitis, and recurrent mastitis has been reported in four to eight-and-a-half percent of breastfeeding women . The most common causative organism of mastitis is Staphylococcus aureus. Other less common organisms include coagulase-negative staphylococci, beta-hemolytic streptococci (Lancefield groups A or B), Escherichia coli, and Corynebacterium species . Streptococcus pneumoniae is an extremely rare cause of mastitis. In this paper, we present the case of a healthy 35-year-old woman who presented to our facility with puerperal pneumococcal mastitis, and review the only three other cases of pneumococcal mastitis described in the medical literature.
Review of the literature of cases of pneumococcal mastitis
First author, year and month published
Age of patient (years)
Time from last birth (months)
Localization of mastitis
Breast culture results (serotype)
Child's culture results
S. pneumoniae type 19A
Vancomycin and cefazolin followed by cefadroxil
Mixed: S. pneumoniae (type not reported) and B. fragilis
Wüst, 1995 (February)
Left breast (lower medial quadrant)
S. pneumoniae (type not reported)
S. pneumoniae (type not reported)
Benzyl penicillin followed by phenoxymethylpenicillin
Kragsbjerg, 1995 (November)
Left breast (upper and lower lateral quadrants)
S. pneumoniae type 6B
S. pneumoniae type 6B
A 35-year-old Caucasian woman who was breastfeeding her eight-month-old twins presented to our facility with a three-day history of fronto-parietal headache, fever, general malaise, and two episodes of syncope on the day of admission. On further questioning, she also reported increasing pain in her right breast over the last 24 hours.
She appeared toxic and was febrile (39.0°C axillary temperature). A physical examination revealed an exquisitely tender right breast that was erythematous and indurated in the right lower lateral quadrant. There was, however, no area of fluctuance although purulent milky secretions could be expelled from the right nipple with mild peri-areolar pressure. These secretions were cultured. Slightly tender right axillary adenopathy was also present.
The results of laboratory investigations were unremarkable, including a normal blood count, except for the presence of a left shift with 80 percent neutrophils (total white blood cell count of 9.8×109 cells/L). Several diagnostic investigations were performed, including a lumbar puncture, cerebral computed tomography (CT) and magnetic resonance imaging (MRI) scans, and blood cultures, all of which yielded normal results. A clinical diagnosis of puerperal mastitis was made, and treatment with intravenous vancomycin and cefazolin was initiated. Our patient continued pumping her breast milk. On the day after admission, increased amounts of pus were noted draining from the right nipple with each breast pumping. Our patient’s fever and rigors resolved within 48 hours. Culture of the breast secretions at the time of admission revealed heavy pure growth of S. pneumoniae, polysaccharide serotype 19A, which was susceptible to penicillin, cephalosporins, macrolides, tetracyclines and vancomycin. Her hospital course was uncomplicated and she was discharged home on day three post-admission with a 10-day course of oral cefadroxil. Neither of her babies showed any evidence of a respiratory tract infection prior to our patient’s illness; nasopharyngeal culture tests from the babies were not performed as they were at home with the father and unavailable for culture sampling.
Pneumococcal mastitis is an extremely rare entity and, to the best of our knowledge, there have been only three other case reports in the literature, two of which were puerperal. S. pneumoniae is a leading cause of respiratory tract infections and meningitis in both children and adults. It is, however, a rare cause of skin and soft-tissue infections and the cases reported are mostly described in patients who have some degree of immunosuppression . Our patient, whose case we present here, was a healthy 35-year-old immunocompetent woman and there were no signs of any connective tissue diseases or other coincidental health issues.
Although neither of her babies showed any evidence of a respiratory tract infection prior to our patient’s illness, and testing of the babies was not undertaken due to their unavailability, it appears that the most probable way in which the mother became infected with S. pneumoniae serotype 19A was from one or both of the nasopharyngeal tracts of the babies during breastfeeding. In both of the previous case reports [4, 5], the breastfed babies had tested positive on nasopharyngeal swabs and showed symptoms of mild respiratory tract infections, which is consistent with our interpretation of the mode of transmission of the S. pneumoniae in mastitis. Our patient's twin babies were both routinely vaccinated at two and four months of age with Prevnar-7® (Wyeth, Collegeville, PA, USA), which contains capsular antigens of S. pneumoniae serotypes 4, 6B, 9V, 14, 18C, 19F, and 23F. Thus, the serotype 19A S. pneumoniae isolated in our patient was not part of the seven-valent pneumococcal conjugate vaccine administered to children in the province of Quebec, where our patient resided at the time of her illness. Current Quebec immunization guidelines recommend vaccination of healthy babies with a pneumococcal seven-valent conjugate vaccine (Prevnar-7®) to be given in three doses administered at two, four and 12 months of age . However, since the introduction of Prevnar-7®, there has been growing concern of the development and spread of the pneumococcal serotypes not covered in the vaccine. A recent review by Reinert et al. describes global indicators showing that serotype 19A is now the most prevalent as well as the most increasingly resistant S. pneumoniae serotype in invasive infections . The most prevalent serotypes involved in invasive disease in Canada at the time of our patient’s presentation were (in descending order): 19A, 7F, 18C, 6A, 22F, 4, 5, 3 and 23B .
Given these findings, the new 13-valent vaccine (Prevnar-13®) that has recently been licensed in Canada, will likely reduce the increasingly prevalent infection rate from the 19A strain of S. pneumoniae. This new vaccine contains the same antigens as Prevnar-7® with six additional capsular antigens of serotypes 1, 3, 5, 6A, 7F and 19A , which together comprise 13 of the 91 S. pneumoniae serotypes described thus far .
This case report highlights the fact that puerperal mastitis may be caused by unusual bacteria, including S. pneumoniae. Immunization of babies with effective pneumococcal vaccines should decrease the incidence of pneumococcal puerperal infections even further, as well as other invasive pneumococcal infections that may be similarly transmitted from baby to mother.
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
We would like to thank our patient for allowing use of her clinical and laboratory information for publication. No financial support has been given for this report.
- Foxman B, D'Arcy H, Gillespie B, Bobo JK, Schwartz K: Lactation mastitis: occurrence and medical management among 946 breastfeeding women in the United States. Am J Epidemiol. 2002, 155: 103-114. 10.1093/aje/155.2.103.View ArticlePubMedGoogle Scholar
- World Health Organization: Mastitis: Causes and Management. WHO/FCH/CAH/00.13. 2000, Geneva, Switzerland: WHOGoogle Scholar
- DiNubile MJ, Albornoz A, Stumacher RJ, Van Uitert BL, Paluzzi SA, Bush LM, Nelson SL, Myers AR: Pneumococcal soft-tissue infections: possible association with connective tissue diseases. J Infect Dis. 1991, 163: 897-900. 10.1093/infdis/163.4.897.View ArticlePubMedGoogle Scholar
- Wüst J, Rutsch M, Stocker S: Streptococcus pneumoniae as an agent of mastitis. Eur J Clin Microbiol Infect Dis. 1995, 14: 156-157. 10.1007/BF02111883.View ArticlePubMedGoogle Scholar
- Kragsbjerg P, Noren T, Soderquist B: Deep soft-tissue infections caused by Streptococcus pneumoniae. Eur J Clin Microbiol Infect Dis. 1995, 14: 1002-1004. 10.1007/BF01691383.View ArticlePubMedGoogle Scholar
- Garcia-Lechuz JM, Cuevas O, Castellares C, Perez-Fernandez C, Cercenado E, Bouza E: Streptococcus pneumoniae skin and soft tissue infections: characterization of causative strains and clinical illness. Eur J Clin Microbiol Infect Dis. 2007, 26: 247-255. 10.1007/s10096-007-0283-7.View ArticlePubMedGoogle Scholar
- Public Health Aganecy of Canada: Publicly funded Immunization Programs in Canada - Routine Schedule for Infants and Children (including special programs and catch-up programs).http://www.phac-aspc.gc.ca/im/ptimprog-progimpt/table-1-eng.php,
- Reinert RR, Jacobs MR, Kaplan S: Pneumococcal disease caused by serotype 19A: review of the literature and implications for future vaccine development. Vaccine. 2010, 28: 4249-4259. 10.1016/j.vaccine.2010.04.020.View ArticlePubMedGoogle Scholar
- Griffith A, Demczuk W, Martin I, Shane A, Tyrrell G, Gilmour MW, the Canadian Public Health Laboratory Network: Distribution of invasive pneumococcal serotypes in Canada: 2010–2011. Abstract #K4. 2012, Vancouver, Canada: AMMI Canada - CACMID Annual ConferenceGoogle Scholar
- Bryant KA, Block SL, Baker SA, Gruber WC, Scott DA, PCV13 Infant Study Group: Safety and immunogenicity of a 13-valent pneumococcal conjugate vaccine. Pediatrics. 2010, 125: 866-875. 10.1542/peds.2009-1405.View ArticlePubMedGoogle Scholar
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.