A case report of Kampo medicine use in severe mastitis

Mastitis frequently manifests within the first 4–6 weeks of lactation and affects approximately 2%–20% of breastfeeding women. The condition typically begins with localized swelling, erythema, and tenderness in the breast, which can intensify and spread beyond specific quadrants. In more severe cases, mastitis may progress to systemic symptoms, including fever and arthralgia, and in the most extreme scenarios, can lead to sepsis. We present a case in which combined Kampo therapy was utilized in managing severe suppurative mastitis complicated by septic shock, suggesting potential benefits of this approach [1]. A 31-year-old woman (Gravida 1, Para 1) with no prior medical history developed left-sided breast pain on postpartum day 31. The patient was 163.0 cm tall, weighed 64.2 kg, and had a body mass index of 24.7. By postpartum day 40, she presented to a local hospital with fever, left breast pain, and edema with facial and bilateral upper-limb erythema. Initial treatment included breast massage, cefalexin, acetaminophen, and an anti-allergy medication. However, her symptoms worsened, and she revisited the hospital. She was admitted for suspected mastitis and urticaria and commenced on tazobactam/piperacillin (TAZ/PIPC) therapy. She subsequently developed shock and was transferred to our facility with a presumptive diagnosis of toxic shock syndrome. Upon arrival at our hospital, she required noradrenaline at 0.05 μg/kg/min and had a blood pressure of 110/71 mm Hg, haeart rate of 123 bpm, a respiratory rate of 26/min, and a body temperature of 38.4°C. She was admitted to the intensive care unit (ICU). A firm, tender mass was palpable in the D region of the left breast. Ultrasound examination revealed an abscess cavity containing fluid and surrounded by a low-echo area. Computed tomography (CT) confirmed a left breast abscess measuring 42 × 38 × 28 mm (Figure 1). Laboratory results showed elevated inflammatory markers, with a white blood cell (WBC) count of 14,300/mL and a C-reactive protein (CRP) level of 13.44 mg/dL. Ultrasound-guided drainage yielded 20 mL of pus, confirming a diagnosis of suppurative mastitis. In addition to drainage, antibiotic therapy with TAZ/PIPC and clindamycin (CLDM) was initiated. Kampo medications, specifically eppikajutsuto (EPTJ) (oral dose: 7.5 g/day, TJ-28; Tsumura & Co., Tokyo, Japan) and hainosankyuto (HNST) (oral dose: 7.5 g/day, TJ-122; Tsumura & Co.), were also administered. On the third day, methicillin-resistant Staphylococcus epidermidis (MRSE) was detected in a breast milk culture. At that time, the blood culture was negative. Although the drainage fluid culture results were pending, Gram-staining of the breast pus suggested Staphylococcus aureus. The patient's condition improved, indicating a favorable response to treatment. Therefore, the MRSE detected in the breast milk culture was considered likely to be contamination. As the patient had recovered from shock, CLDM was discontinued. Following stabilization, the patient was transferred from the ICU to the breast surgery unit, where ultrasound-guided drainage and irrigation of the abscess cavity were performed daily. By the eighth day, her WBC count had decreased to 6100/mL, and her CRP level had dropped to 1.24 mg/dL. She was discharged on the eleventh day in stable condition. Antibiotic and Kampo therapies were continued for a total of 19 days. Cytology results indicated no malignancy. Mastitis is often associated with infections by Staphylococcus or Streptococcus species. Prompt antibiotic therapy is advised if symptoms persist beyond 24–48 hours despite symptomatic treatment [1]. Considering senkyu-kokan including Western medicine, drainage of the abscess and prompt administration of antibiotics should be prioritized in the management of sepsis. Some studies suggest that Kampo formulas such as kakkonto can reduce the need for antibiotics in mastitis management [2]. Other Kampo formulations, including saireito, juzentaihoto, shosaikoto, and keibohaidokusan, have been utilized in mastitis cases, though data on their use in severe presentations are limited [3, 4]. Given the specific circumstances of postpartum recovery, it is plausible that physiological changes during this period led to a transient imbalance, which may account for the rapid exacerbation of her condition. Therefore, we employed a combination of HNST and EPTJ with antibiotics. HNST comprises Platycodon root, immature orange, peony root, Glycyrrhiza root, jujube, and ginger, providing heat-clearing, detoxifying, expectorant, and drainage-promoting effects. As a result, it has been traditionally used for treating pyogenic skin and mucosal diseases. EPTJ, composed of gypsum, Ephedra herb, Atractylodes lancea rhizome, jujube, Glycyrrhiza root, and ginger, is indicated for the treatment of acute joint swelling, pain, and fever. Gypsum contributes a heat-clearing effect, and we have previously reported its efficacy in treating cellulitis [5]. In this case, the combined anti-inflammatory and drainage effects of HNST and the antipyretic and diuretic effects of EPTJ appeared to enhance the effectiveness of drainage and antibiotic therapy. Each 7.5 g dose of HNST contains 3.0 g of Glycyrrhiza, while EPTJ contains 2.0 g, presenting a potential risk of pseudoaldosteronism; however, no such symptoms were observed during the 16-day course. EPTJ also contains Ephedra, which may cause side effects such as insomnia, hypertension, and urinary retention due to ephedrine effects, though these were not observed in this case. In conclusion, this case suggests that Kampo therapy with HNST and EPTJ, combined with drainage and antibiotic treatment, may provide a safe and effective option for severe suppurative mastitis. Further multicenter prospective studies are needed to determine whether the concomitant use of Kampo medicines is mandatory. Hajime Nakae received honoraria from the Tsumura Co. The other authors declare no conflicts of interest. We obtained written informed consent from the patient. N/A. N/A. N/A.