J Pediatr Endocr Met 2012;25(1-2):163–164 © 2012 by Walter de Gruyter • Berlin • Boston. DOI 10.1515/jpem-2011-0460 *Corresponding author: Dragana Djilas-Ivanovic, Diagnostic Imaging Centre, Oncology Insitute of Vojvodina, Institutski put 4, Sremska Kamenica 21204, Serbia E-mail: [email protected] Received November 26, 2011; accepted December 15, 2011; previously published online January 25, 2012 Bilateral bloody nipple discharge in a male infant: sonographic findings and proposed diagnostic approach Dragana Djilas-Ivanovic 1, *, Jasmina Boban 1 , Dragan Katanic 2 , Tatjana Ivkovic-Kapicl 3 and Milos Alexandar Lucic 1 1 Diagnostic Imaging Centre, Oncology Institute of Vojvodina, Sremska Kamenica, Serbia 2 Endocrinology Department, Institute for Children and Youth Health Care of Vojvodina, Novi Sad, Serbia 3 Pathology Department, Oncology Institute of Vojvodina, Sremska Kamenica, Serbia Abstract Bloody nipple discharge is an uncommon finding in the pedi- atric population, without clear diagnostic and therapeutic guidelines established. We noted a case of a 3-month-old male infant who presented with bilateral blood-stained nipple dis- charge, with unremarkable medical history. Sonographic find- ings revealed bilaterally dilated ducts and cysts with mixed iso- and hypoechoic intraductal content. Possible causes of this condition include hyperlaxity syndrome with decreased function of elastic fibers and fibrocystic changes in breasts, and unusual response to maternal hormones, transferred to the neonate either transplacentally or through breastfeeding. Given the most probable benign etiology and self-limiting nature of the described condition, a conservative approach is suggested. Unnecessary invasive procedures should be avoided. Keywords: bloody nipple discharge; breast ultrasound; infant. Introduction Bloody nipple discharge is an uncommon finding in the pedi- atric population, without clear diagnostic and therapeutic guidelines established (1–4). It is thought to be a self-limiting benign process related to hormonal adaptation of the infant in the early age. Although benign, the condition causes severe anxiety in parents. There are very few cases described in the literature, with only one reporting sonographic findings (5). Case report We report a case of a 3-month-old boy presenting with bilat- eral sanguinous discharge without signs of significant breast hypertrophy or infection associated. The discharge was bloody at the time it was noticed. The parents denied any manipula- tion with the breast tissue. Medical history was unremark- able. However, family medical history included breast cancer in the patient’s mother’s family, and generalized hyperlaxity syndrome. The child was breastfed. On the physical examination, there were small palpable masses in both breasts, with no significant enlargement of breast tissue. There were small blood stains at the levels of nipples on the patient’s shirt. Breast sonography was performed using a Voluson 730 Pro scanner with a SP 10–16 MHz linear probe (GE Medical Systems, Milwaukee, WI, USA). Sonographic findings revealed bilaterally dilated ducts measuring up to 4 mm in diameter. In the retromammilar region of the left breast, several cysts with mixed iso- and hypoechoic intraductal content were found (Figure 1A–C). All endocrinologic findings and hormone level results were within reference ranges. Discussion There are several cases of bloody nipple discharge reported in the literature, with only one case describing sonographic findings (5). In a few cases, biopsy and mastectomy were per- formed, showing the same type of benign duct ectasia seen in adults (4, 6–8). It is a benign process of duct dilatation surrounded by periductal fibrous tissue and inflammatory reaction. Several etiologic factors were taken into account, with- out clear evidence to favor any of these (9). It is thought that the cause can be an unusual response to maternal hormones, transferred to the neonate either transplacentally or through breastfeeding. There are no studies found in the literature concerning the type of feeding in relation to bloody nipple discharge. However, Kelly et al. (3) reported spontaneous restitution of the discharge 1 month after discontinuation of breastfeeding. Nevertheless, this state was documented in both breast- and formula-fed infants, which downgrades the role of breastfeeding in this condition. There are some additional clinical conditions that can lead to bloody nipple discharge. Brought to you by | Hiroshima Jogakuin Authenticated | 147.91.173.31 Download Date | 1/10/14 7:22 AM
Bilateral bloody nipple discharge in a male infant: sonographic fi ndings and proposed diagnostic approach
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jpem20110460.inddJ Pediatr Endocr Met 2012;25(1-2):163–164 © 2012 by Walter de Gruyter • Berlin • Boston. DOI 10.1515/jpem-2011-0460
*Corresponding author: Dragana Djilas-Ivanovic, Diagnostic Imaging Centre, Oncology Insitute of Vojvodina, Institutski put 4, Sremska Kamenica 21204, Serbia E-mail: [email protected] Received November 26, 2011; accepted December 15, 2011; previously published online January 25, 2012
Bilateral bloody nipple discharge in a male infant: sonographic fi ndings and proposed diagnostic approach
Dragana Djilas-Ivanovic 1, *, Jasmina Boban 1 , Dragan Katanic 2 , Tatjana Ivkovic-Kapicl 3 and Milos Alexandar Lucic 1
1 Diagnostic Imaging Centre , Oncology Institute of Vojvodina, Sremska Kamenica , Serbia 2 Endocrinology Department , Institute for Children and Youth Health Care of Vojvodina, Novi Sad , Serbia 3 Pathology Department , Oncology Institute of Vojvodina, Sremska Kamenica , Serbia
Abstract
Bloody nipple discharge is an uncommon fi nding in the pedi- atric population, without clear diagnostic and therapeutic guidelines established. We noted a case of a 3-month-old male infant who presented with bilateral blood-stained nipple dis- charge, with unremarkable medical history. Sonographic fi nd- ings revealed bilaterally dilated ducts and cysts with mixed iso- and hypoechoic intraductal content. Possible causes of this condition include hyperlaxity syndrome with decreased function of elastic fi bers and fi brocystic changes in breasts, and unusual response to maternal hormones, transferred to the neonate either transplacentally or through breastfeeding. Given the most probable benign etiology and self-limiting nature of the described condition, a conservative approach is suggested. Unnecessary invasive procedures should be avoided.
Keywords: bloody nipple discharge; breast ultrasound; infant.
Introduction
Bloody nipple discharge is an uncommon fi nding in the pedi- atric population, without clear diagnostic and therapeutic guidelines established (1 – 4) . It is thought to be a self-limiting benign process related to hormonal adaptation of the infant in the early age. Although benign, the condition causes severe anxiety in parents. There are very few cases described in the literature, with only one reporting sonographic fi ndings (5) .
Case report
We report a case of a 3-month-old boy presenting with bilat- eral sanguinous discharge without signs of signifi cant breast hypertrophy or infection associated. The discharge was bloody at the time it was noticed. The parents denied any manipula- tion with the breast tissue. Medical history was unremark- able. However, family medical history included breast cancer in the patient ’ s mother ’ s family, and generalized hyperlaxity syndrome. The child was breastfed.
On the physical examination, there were small palpable masses in both breasts, with no signifi cant enlargement of breast tissue. There were small blood stains at the levels of nipples on the patient ’ s shirt.
Breast sonography was performed using a Voluson 730 Pro scanner with a SP 10 – 16 MHz linear probe (GE Medical Systems, Milwaukee, WI, USA). Sonographic fi ndings revealed bilaterally dilated ducts measuring up to 4 mm in diameter. In the retromammilar region of the left breast, several cysts with mixed iso- and hypoechoic intraductal content were found (Figure 1 A – C).
All endocrinologic fi ndings and hormone level results were within reference ranges.
Discussion
There are several cases of bloody nipple discharge reported in the literature, with only one case describing sonographic fi ndings (5) . In a few cases, biopsy and mastectomy were per- formed, showing the same type of benign duct ectasia seen in adults (4, 6 – 8) . It is a benign process of duct dilatation surrounded by periductal fi brous tissue and infl ammatory reaction.
Several etiologic factors were taken into account, with- out clear evidence to favor any of these (9) . It is thought that the cause can be an unusual response to maternal hormones, transferred to the neonate either transplacentally or through breastfeeding. There are no studies found in the literature concerning the type of feeding in relation to bloody nipple discharge. However, Kelly et al. (3) reported spontaneous restitution of the discharge 1 month after discontinuation of breastfeeding. Nevertheless, this state was documented in both breast- and formula-fed infants, which downgrades the role of breastfeeding in this condition.
There are some additional clinical conditions that can lead to bloody nipple discharge.
Brought to you by | Hiroshima Jogakuin Authenticated | 147.91.173.31
Download Date | 1/10/14 7:22 AM
164 Djilas-Ivanovic et al.: Bilateral bloody nipple discharge in a male infant
Recently, some work has been done in defi ning the rela- tion between hyperlaxity syndrome with decreased function of elastic fi bers and fi brocystic changes in breasts. These changes result in increased fragility of capillaries, which may be the cause of the hemorrhagic content of nipple dis- charge (10) . Mastitis commonly presents with breast pain and erythema, but rarely includes bloody nipple discharge. Also, it is followed by clear signs of infection and usually occurs before 6 weeks of age. To the best of our knowl- edge, breast malignancy, which would be the most common cause of bloody discharge in adults, in infancy has not been described in the literature (10) . Finally, pituitary adenomas often present with nipple discharge, but it is usually milky and bilateral.
Given the most probable benign etiology and self-limiting nature of the described condition, a conservative approach is suggested. Diagnostic protocol should, however, include Gram staining, cell count and culture of the discharge, determination of serum levels of specifi c hormones (pro- lactin, estradiol, thyrotropin), and ultrasound follow-up. When hyperlaxity syndrome is suspected, copper, which is essential for synthesis of elastin fi bers, can be applied orally. Pediatric surgical consultation and therapy should be consid- ered in case of a sonographic fi nding of mass and abnormal- ity. Otherwise, unnecessary invasive procedures should be avoided.
References
1. Leung AK, Kao CP. Mammary duct ectasia: a cause of bloody nipple discharge. J Natl Med Assoc 2004;96:543 – 5.
2. Bober E, Ozer E, Akgur F, B ü y ü kgebiz A. Bilateral breast masses and bloody nipple discharge in two-year old boy. J Pediatr Endocrinol Metab 1996;9:419 – 21.
3. Kelly VM, Arif K, Ralston S, Greger N, Scott S. Bloody nipple discharge in an infant and a proposed diagnostic approach. Pediatrics 2006;117:814 – 6.
4. Kitahara S, Wakabayashi M, Shiba T, Nonaka K, Nonaka H, et al. Mammary duct ectasia in children presenting bloody nipple discharge: a case in a pubertal girl. J Pediatr Surg 2001;36:E2.
5. Bayrak IL, Yalin T, Nural MS, Ceyhan M. Mammary duct ectasia in infant breast with bloody nipple discharge: sonographic fi nd- ings. J Clin Ultrasound 2008;36:229 – 30.
6. 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.
7. Stringel G, Perelman A, Jimenez C. Infantile mammary duct ectasia: a cause of bloody nipple discharge. J Pediatr Surg 1986;21:671 – 4.
8. Al-Arfaj AA, Chir AF, Mitra DK, Sowayan SA. Bloody nipple dis- charge in a four-year-old child. Ann Saudi Med 2003;23:175 – 6.
9. Berkowitz CD, Inkelis SH. Bloody nipple discharge in infancy. J Pediatr 1983;103:755 – 6.
10. Longo OA, Mosto A, Moran JC, Mosto J, Rives LE, et al. Breast carcinoma in childhood and adolescence: case report and review of the literature. Breast J 1999;5:65 – 9.
Figure 1 Sonograms of the (A) right and (B) left breasts showing bilaterally dilated ducts measuring up to 4 mm in diameter. In the retromam- milar region of the left breast (C), several cystic ducts with mixed iso- and hypoechoic intraductal content were found. Echogenic component inside the cysts and ducts is believed to represent blood degradation products.
Brought to you by | Hiroshima Jogakuin Authenticated | 147.91.173.31
Download Date | 1/10/14 7:22 AM
*Corresponding author: Dragana Djilas-Ivanovic, Diagnostic Imaging Centre, Oncology Insitute of Vojvodina, Institutski put 4, Sremska Kamenica 21204, Serbia E-mail: [email protected] Received November 26, 2011; accepted December 15, 2011; previously published online January 25, 2012
Bilateral bloody nipple discharge in a male infant: sonographic fi ndings and proposed diagnostic approach
Dragana Djilas-Ivanovic 1, *, Jasmina Boban 1 , Dragan Katanic 2 , Tatjana Ivkovic-Kapicl 3 and Milos Alexandar Lucic 1
1 Diagnostic Imaging Centre , Oncology Institute of Vojvodina, Sremska Kamenica , Serbia 2 Endocrinology Department , Institute for Children and Youth Health Care of Vojvodina, Novi Sad , Serbia 3 Pathology Department , Oncology Institute of Vojvodina, Sremska Kamenica , Serbia
Abstract
Bloody nipple discharge is an uncommon fi nding in the pedi- atric population, without clear diagnostic and therapeutic guidelines established. We noted a case of a 3-month-old male infant who presented with bilateral blood-stained nipple dis- charge, with unremarkable medical history. Sonographic fi nd- ings revealed bilaterally dilated ducts and cysts with mixed iso- and hypoechoic intraductal content. Possible causes of this condition include hyperlaxity syndrome with decreased function of elastic fi bers and fi brocystic changes in breasts, and unusual response to maternal hormones, transferred to the neonate either transplacentally or through breastfeeding. Given the most probable benign etiology and self-limiting nature of the described condition, a conservative approach is suggested. Unnecessary invasive procedures should be avoided.
Keywords: bloody nipple discharge; breast ultrasound; infant.
Introduction
Bloody nipple discharge is an uncommon fi nding in the pedi- atric population, without clear diagnostic and therapeutic guidelines established (1 – 4) . It is thought to be a self-limiting benign process related to hormonal adaptation of the infant in the early age. Although benign, the condition causes severe anxiety in parents. There are very few cases described in the literature, with only one reporting sonographic fi ndings (5) .
Case report
We report a case of a 3-month-old boy presenting with bilat- eral sanguinous discharge without signs of signifi cant breast hypertrophy or infection associated. The discharge was bloody at the time it was noticed. The parents denied any manipula- tion with the breast tissue. Medical history was unremark- able. However, family medical history included breast cancer in the patient ’ s mother ’ s family, and generalized hyperlaxity syndrome. The child was breastfed.
On the physical examination, there were small palpable masses in both breasts, with no signifi cant enlargement of breast tissue. There were small blood stains at the levels of nipples on the patient ’ s shirt.
Breast sonography was performed using a Voluson 730 Pro scanner with a SP 10 – 16 MHz linear probe (GE Medical Systems, Milwaukee, WI, USA). Sonographic fi ndings revealed bilaterally dilated ducts measuring up to 4 mm in diameter. In the retromammilar region of the left breast, several cysts with mixed iso- and hypoechoic intraductal content were found (Figure 1 A – C).
All endocrinologic fi ndings and hormone level results were within reference ranges.
Discussion
There are several cases of bloody nipple discharge reported in the literature, with only one case describing sonographic fi ndings (5) . In a few cases, biopsy and mastectomy were per- formed, showing the same type of benign duct ectasia seen in adults (4, 6 – 8) . It is a benign process of duct dilatation surrounded by periductal fi brous tissue and infl ammatory reaction.
Several etiologic factors were taken into account, with- out clear evidence to favor any of these (9) . It is thought that the cause can be an unusual response to maternal hormones, transferred to the neonate either transplacentally or through breastfeeding. There are no studies found in the literature concerning the type of feeding in relation to bloody nipple discharge. However, Kelly et al. (3) reported spontaneous restitution of the discharge 1 month after discontinuation of breastfeeding. Nevertheless, this state was documented in both breast- and formula-fed infants, which downgrades the role of breastfeeding in this condition.
There are some additional clinical conditions that can lead to bloody nipple discharge.
Brought to you by | Hiroshima Jogakuin Authenticated | 147.91.173.31
Download Date | 1/10/14 7:22 AM
164 Djilas-Ivanovic et al.: Bilateral bloody nipple discharge in a male infant
Recently, some work has been done in defi ning the rela- tion between hyperlaxity syndrome with decreased function of elastic fi bers and fi brocystic changes in breasts. These changes result in increased fragility of capillaries, which may be the cause of the hemorrhagic content of nipple dis- charge (10) . Mastitis commonly presents with breast pain and erythema, but rarely includes bloody nipple discharge. Also, it is followed by clear signs of infection and usually occurs before 6 weeks of age. To the best of our knowl- edge, breast malignancy, which would be the most common cause of bloody discharge in adults, in infancy has not been described in the literature (10) . Finally, pituitary adenomas often present with nipple discharge, but it is usually milky and bilateral.
Given the most probable benign etiology and self-limiting nature of the described condition, a conservative approach is suggested. Diagnostic protocol should, however, include Gram staining, cell count and culture of the discharge, determination of serum levels of specifi c hormones (pro- lactin, estradiol, thyrotropin), and ultrasound follow-up. When hyperlaxity syndrome is suspected, copper, which is essential for synthesis of elastin fi bers, can be applied orally. Pediatric surgical consultation and therapy should be consid- ered in case of a sonographic fi nding of mass and abnormal- ity. Otherwise, unnecessary invasive procedures should be avoided.
References
1. Leung AK, Kao CP. Mammary duct ectasia: a cause of bloody nipple discharge. J Natl Med Assoc 2004;96:543 – 5.
2. Bober E, Ozer E, Akgur F, B ü y ü kgebiz A. Bilateral breast masses and bloody nipple discharge in two-year old boy. J Pediatr Endocrinol Metab 1996;9:419 – 21.
3. Kelly VM, Arif K, Ralston S, Greger N, Scott S. Bloody nipple discharge in an infant and a proposed diagnostic approach. Pediatrics 2006;117:814 – 6.
4. Kitahara S, Wakabayashi M, Shiba T, Nonaka K, Nonaka H, et al. Mammary duct ectasia in children presenting bloody nipple discharge: a case in a pubertal girl. J Pediatr Surg 2001;36:E2.
5. Bayrak IL, Yalin T, Nural MS, Ceyhan M. Mammary duct ectasia in infant breast with bloody nipple discharge: sonographic fi nd- ings. J Clin Ultrasound 2008;36:229 – 30.
6. 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.
7. Stringel G, Perelman A, Jimenez C. Infantile mammary duct ectasia: a cause of bloody nipple discharge. J Pediatr Surg 1986;21:671 – 4.
8. Al-Arfaj AA, Chir AF, Mitra DK, Sowayan SA. Bloody nipple dis- charge in a four-year-old child. Ann Saudi Med 2003;23:175 – 6.
9. Berkowitz CD, Inkelis SH. Bloody nipple discharge in infancy. J Pediatr 1983;103:755 – 6.
10. Longo OA, Mosto A, Moran JC, Mosto J, Rives LE, et al. Breast carcinoma in childhood and adolescence: case report and review of the literature. Breast J 1999;5:65 – 9.
Figure 1 Sonograms of the (A) right and (B) left breasts showing bilaterally dilated ducts measuring up to 4 mm in diameter. In the retromam- milar region of the left breast (C), several cystic ducts with mixed iso- and hypoechoic intraductal content were found. Echogenic component inside the cysts and ducts is believed to represent blood degradation products.
Brought to you by | Hiroshima Jogakuin Authenticated | 147.91.173.31
Download Date | 1/10/14 7:22 AM
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