Bilateral Nipple Piercings and Subsequent Methicillin-Resistant Staphylococcus Aureus Breast Abscess Formation

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Body piercings have become an increasingly popular form of body modification. The ears are the most common site of piercings, but intimate body piercings have increased in prevalence. The breast is the most common intimate body piercing, with 1 study reporting that an estimated 9% of women in the United States have their breasts pierced.¹

Breast infections in adults and adolescents tend to present with pain and erythema, and ultrasound is usually recommended to differentiate cellulitis from abscesses.² However, if not promptly identified and treated, more significant sequelae, such as abscess formation or toxic shock syndrome, can ensue.

While Staphylococcus aureus is the most common cause of breast infections, individuals with a history of nipple piercing necessitate a wider scope of potential causative organisms.^3,4 In the presence of an abscess, percutaneous drainage is preferred. Open surgical drainage is usually needed for multiloculated abscesses, abscesses greater than 5 cm, cases with systemic sepsis, or recurrent abscesses.^5,6 This article presents the case of a patient who developed a right breast abscess about 7 weeks after bilateral nipple piercings.

A 39-year-old female with a past medical history of polycystic ovarian syndrome presented with progressively worsening pain and a palpable lump on the right breast for several days. She had obtained bilateral nipple piercings 7 weeks prior. Additionally, she had undergone bilateral breast reduction approximately 10 months prior and scar revision operations approximately 1 month prior to the onset of infection (Figure 1). Upon presentation, the patient was afebrile without skin discoloration but was tender to palpation superior to the right nipple. The breast reduction and revision procedure scars were intact. Ultrasound and mammogram demonstrated significant edema, which was deemed to be mastitis. She was prescribed a 10-day course of cephalexin and instructed to follow up as soon as possible.

Figure 1. The right breast at baseline. This is about 1 month prior to presentation when the patient was prepared for lateral scar vision from a former breast reduction.

The following day, she was seen in clinic with worsening swelling, tenderness, pain, and erythema of the right breast. She had remained afebrile, and denied any purulence or drainage from incision sites or nipples. Physical examination demonstrated a well-demarcated area of fluctuance on the right breast superolateral to the nipple with overlying erythema.

She was admitted for ultrasound-guided drainage of fluid collection with culture. Intravenous vancomycin and piperacillin-tazobactam were initiated. White blood cell counts (WBC) and C-reactive protein (CRP) levels were elevated on intake lab work. The day after admission, ultrasound of the right breast demonstrated multiple pockets of fluid, with the largest measuring 4.5 x 1.6 x 4.1 cm. Aspiration of this pocket yielded about 15 mL of bloody, purulent fluid that was sent for gram stain and culture.

On admission day 3, she was taken to the operating room for incision and drainage (Figure 2). An incision was made at the inframammary fold. Clamps and finger dissection were used to break up loculations of the abscess. Purulent fluid was taken for gram stain, aerobic, anaerobic, and mycobacterial cultures (Figure 3). The wound was copiously irrigated with an antibiotic solution, and the breast was packed with dilute betadine-soaked gauze bandage rolls.

Figure 2. Incision and drainage of the preoperative breast. This preoperative photograph was taken just prior to incision. The drainage shows the increased edema and erythema from baseline that was associated with the underlying infection.

Figure 3. Intraoperative view of the abscess cavity. This shows the purulent fluid found within the abscess cavity that was sent for gram stain, aerobic, anaerobic, and mycobacterial cultures.

The patient remained in the hospital for 2 more days. Cultures yielded methicillin-resistant Staphylococcus aureus (MRSA). Vancomycin was continued throughout duration of admission, and her WBC count and CRP decreased. She was discharged with a 14-day course of doxycycline.

She completed the course of doxycycline and managed her wound with twice daily wet-to-dry dressings using normal saline (Figure 4). She was most recently seen 6 weeks following the admission without recurrence of abscess or infection. She formed immature scar tissue laterally and continued to pack the open medial wound with wet-to-dry dressings.

Figure 4. Postoperative view of surgical incision. The healing inframammary wound on postoperative day 20 shows early healing after wet-to-dry dressings.

The skin is ubiquitously harbored by bacterial flora. Piercings threaten the skin barrier and facilitate migration of bacteria into areas such as the breast ductal system. Breast infections have been a hot topic within the plastic surgery community, and many argue breast surgeries be reclassified as clean-contaminated operations because of heightened postoperative infection rates. The lack of adequate skin preparation compounded with the local trauma creates a framework for infection.

This case was unique in that there was an extended period of 7 weeks from the initial nipple piercing to the breast abscess formation. It is difficult to determine whether the infectious inoculation occurred at the time of piercing with a lengthy subclinical course, or if there was a secondary introduction of infection later through the microtrauma caused by the piercing.

Additionally, for a breast abscess, this presentation was atypical in that it did not present with a clearly swollen, erythematous, tender breast. The ultrasound was useful for diagnosis by demonstrating multiple fluid collections. Because various pockets of fluid existed rather than a single clear abscess, surgery was preferred over a percutaneous drainage method. In addition, given the location around the nipple, it was important to consider the cosmetic aspects of drainage. Our use of an inframammary incision was cosmetically pleasing but was more challenging, especially in accessing the upper pole of the breast.

While reported incidents remain scarce in the literature, a systemic review of the published cases found Mycobacterium fortuitum, Staphylococcus epidermidis, Neisseria gonorrhoeae, S. aureus, Streptococcus agalactiae, and Propionibacterium acnes to be the most frequently isolated species in infection following nipple piercing. Identified antecedents that could have contributed to the infectious presentations include exposure of the pierced nipple during sexual contact, swimming in dirty water, or contact of the pierced nipple with contaminated objects. Most of the patients presented with symptoms 1 month to 1 year after nipple piercing with clinical pictures including breast fluid collection, pain, swelling, erythema, or granulomatous tissue.⁷

While there are policies in place on a state-by-state basis to regulate body piercing practices for businesses, it is difficult to assess how effectively these rules are enforced. In West Virginia, Body Piercing Studio Business Rule 64-80 was enacted in 2001 to improve the safety of body piercing.⁸ However, it is important to note that this safeguards approved and compliant businesses and does not consider piercings completed in noncompliant studios or other environments. Ultimately, a thorough patient history would provide the greatest insight into the safety and hygiene practices utilized by the piercer. Additionally, a plastic surgeon’s armamentarium must include the skillset necessary to handle abscesses such as these, especially in the rural setting.⁹

The presented report highlights a case of MRSA abscess development in the time following a nipple piercing. A review of the literature, including other cases and associated infectious organisms, was also discussed. Unique cases like this are important additions to the scientific literature because they can provide evidence to guide the management of similar conditions and emphasize the need for stricter piercing policies, which could improve public health and sanitation.