Breast Abscess After Nipple Piercing

A 29-year-old sailor presented with a painless, enlarging, reddish, mobile lump under his left nipple. Four months earlier, while on deployment in the South Pacific, he had his nipples pierced on a whim. At the piercing studio, he purchased 2 barbell-type nipple rings that were individually packaged and autoclaved. Povidone-iodine was applied to his skin, and the nipples were pierced with a large-bore needle. He was instructed to wash the area daily and leave the jewelry in for at least 3 months.

The patient's left nipple ring fell out about 2 months after the piercing. He noticed the lump about 6 weeks later.

The lesion failed to resolve after a 10-day course of cephalexin. An ultrasonogram revealed a 2.1 × 0.6 × 2.5-cm fluid collection below the left areola. Fine-needle aspiration was performed, and oral clindamycin was started. Culture of the aspirate grew Mycobacterium fortuitum.

The patient was hospitalized for intravenous antibiotic therapy. On admission, the red, indurated, 2 3 4-cm mass was palpable just beneath the left nipple (Figure). The patient denied any history of fever, chills, or malaise.

After a week of intravenous therapy with amikacin plus cefoxitin and oral therapy with clarithromycin, the patient was discharged with a peripherally inserted central catheter for daily intravenous therapy with amikacin and meropenem. This regimen was continued for 2 weeks, followed by an additional 8 weeks of oral clarithromycin.

Reports of mastitis after nipple piercing have increased in the past decade.^1-4 Most cases involve Staphylococcus aureus; cases of Mycobacterium infection have been reported.¹ Rapidly growing mycobacteria are known to infect surgical and traumatic wounds.⁵

Mycobacterial infections have been described as cold abscesses because of the absence of cellulitis, tenderness, and inflammation. This patient's indolent presentation was consistent with mycobacterial infection. The noninflammatory clinical presentation may raise suspicion of cancer and lead to an unneces- sary extensive workup and patient anxiety.¹

Clinical presentation. In a review of 10 cases of breast abscess after nipple piercing, the average patient age was 31 years and the female to male ratio was 7:3; symptoms occurred an average of 20 weeks after the piercing and lasted from 1 week to several months.¹ In most cases (7 of 10 patients), infection developed 4 to 12 months after the piercing. The reason for this delay is unclear. It may be because of the microorganism's long incubation period or because of later contamination of the piercing site during the slow healing period.¹

Complications associated with nipple piercing. The estimated risk of mastitis after nipple piercing is 20%.² Other complications associated with nipple piercing include endocarditis (in a patient with a bicuspid aortic valve),⁶ breast implant infections,¹ incursion of a metallic foreign body into breast tissue,² and hyperprolactinemia.⁷ Psychological and financial burdens are less obvious complications of breast infections after a nipple piercing. These may include anxiety about cancer before the diagnosis is confirmed and missed work and high medical bills because of prolonged intravenous treatment.¹

Treatment. The ornament or nidus of infection must be removed. Obtain cultures and sensitivities to guide therapy; empiric antibiotic treatment is not recommended. Test for mycobacteria as well as for hepatitis B and C viruses.

Prevalence. One study found that of persons with a body piercing, 10.2% were aged 12 to 15 years, 47.6% were 16 to 20 years, and 26.7% were 21 to 25 years.¹ In another study, 51% of 454 college students had a piercing; the most commonly pierced sites were the ear and navel.⁸ The tragus, helix, eyebrow, nasal septum, lip, tongue, and nipple were other pierced sites. "Less traditional" sites include the uvula, cheek, chest, neck, and knuckles. Anecdotal evidence suggests that the ears, navel, eyebrows, and nose are popular piercing sites among 18- to 24-year-olds, while nipple, tongue, and genital piercings are more often obtained by those in their 30s.⁹

Pocketing is another variant of piercing, in which a bar is placed under an area of skin and each end of the bar is embedded.¹⁰ Up to 18% of persons with a body piercing voluntarily remove their jewelry because of dissatisfaction or infection.⁹

The procedure. Before a piercing, the skin is cleaned with alcohol and iodine, and the desired site is retracted with forceps. A 12- to 16-gauge needle is forced through the skin, and the jewelry is guided through the hole with the needle. The needle is then removed, leaving the jewelry in place. This is done without local anesthesia. The client is instructed to clean the area twice a day with antimicrobial soap and to refrain from touching the site.⁹

The needle-piercing method is superior to piercing guns, which are more difficult to keep sterile.¹¹ Using gold or silver jewelry and keeping the jewelry in place help reduce the risk of infection.^9,12

Before piercing. Although no universal guidelines on body piercing have been established, several contraindications to nipple piercing have been proposed (Table).¹ Offer patients who are considering piercing, particularly adolescents, the following advice⁹:

• Talk to persons who have been pierced about their experience.
• Do not undergo piercing while intoxicated.
• Visit the piercing studio beforehand; make sure the procedure is done with sterile gloves and needles and prepackaged ornaments.
• Be aware that no anesthetic is used during the procedure.

After piercing. Often, patients with a piercing-associated infection delay seeking medical care. These patients may be reluctant to have the ornament removed, or they may fear censure from the treating physician. Thus, it is especially important to be nonjudgmental when counseling patients about piercing complications.