|Year : 2012 | Volume
| Issue : 2 | Page : 144-146
Non-specific granulomatous or tuberculous mastitis
Gurjit Singh, Trinath Tummetalli
Department of Surgery, Padmashree Dr. D. Y. Patil Hospital and Medical College, S. T. Nagar, Pimpri, Pune, Maharashtra, India
|Date of Web Publication||10-Nov-2012|
Department of Surgery, Padmashree Dr. D. Y. Patil Hospital and Medical College, S.T. Nagar, Pimpri, Pune - 411018, Maharashtra
Source of Support: None, Conflict of Interest: None
The significance of breast tuberculosis is due to rare occurrence and mistaken identity with breast cancer and pyogenic breast abscess. A 70-year-old woman presented with a gradually increasing swelling in the right breast involving the outer upper quadrant since 6 months. Examination of the axilla revealed no lymphadenopathy. FNAC from the lump was inconclusive. Straw-colored discharge from the FNAC site was negative for acid-fast bacilli on Z-N staining and on culture. Modified radical mastectomy was done since malignancy could not be ruled out. Histopathology showed features of granulomatous mastitis. Lymph nodes recovered from the specimen showed caseation necrosis. Anti-tubercular treatment was given to the patient, and she has remained asymptomatic over 1 year of follow-up so far. Extrapulmonary tuberculosis occurring in the breast is extremely rare and is uncommon even in countries where the incidence of pulmonary and extrapulmonary tuberculosis is high.
Keywords: Extrapulmonary tuberculosis, granulomatous mastitis, tuberculous mastitis
|How to cite this article:|
Singh G, Tummetalli T. Non-specific granulomatous or tuberculous mastitis. Med J DY Patil Univ 2012;5:144-6
| Introduction|| |
The significance of breast tuberculosis is due to rare occurrence and mistaken identity with breast cancer and pyogenic breast abscess.  Breast tuberculosis has been scarcely reported even from endemic areas until lately when several reports have come up from South Africa and India. The incidence of tubercular mastitis although decreasing in the West, could show a resurgence with the global pandemic of AIDS.
Over the years since the first description of tubercular mastitis in 1829, the incidence, clinical presentation, diagnostic and treatment methodology of breast tuberculosis have gradually changed.  This case report also discusses the important issues relating to the diagnosis, clinical features and management of breast tuberculosis.
| Case Report|| |
A 70-year-old woman presented with a gradually increasing swelling in the right breast involving the outer upper quadrant since 6 months. There was no association of pain, fever, trauma or discharge through nipple with the swelling. The lump 12 x 10 cm in size in upper outer quadrant of breast was soft, non-tender and cystic in consistency. X-ray of the chest was normal.
Examination of the axilla revealed no lymphadenopathy. FNAC from the lump was inconclusive. Straw-colored discharge from the FNAC site was examined, which was negative for acid-fast bacilli on Z-N staining and on culture. Ultrasound revealed a cystic lesion containing fluid, which was confined to the breast tissue.
Modified radical mastectomy was done since malignancy could not be ruled out since FNAC was inconclusive. However a tru-cut biopsy was not done. Histopathology showed features of granulomatous mastitis. Lymph nodes recovered from the specimen showed caseation necrosis. Anti-tubercular treatment was given to the patient, and she has remained asymptomatic over 1 year of follow-up so far.
| Discussion|| |
Breast tuberculosis is a rare form of tuberculosis. , The first case of mammary tuberculosis was recorded by Sir Astley Cooper in 1829 who called it "scrofulous swelling of the bosom." A literature review by Morgan in 1931,  revealed 439 cases of tubercular mastitis with the incidence between 0.5% and 1.04%. In 1944, Klossner  reported 50 cases of breast tuberculosis in women, out of 75,000 women with pulmonary tuberculosis with lung involvement. Of approximately 8,000 breast specimens studied, Haagensen  reported only 5 cases of breast tuberculosis between 1938 and 1967. Only 500 cases were documented from the world literature by Hamit and Ragsdale in 1982.  Since then, case reports and reviews have been published at infrequent intervals mostly in western literature.
The incidence of tuberculosis, in general, is still quite high in India and so is expected of the breast tuberculosis.  Less than 100 cases of breast tuberculosis were reported from India till 1987.  The first 13 cases of breast tuberculosis from India were reported by Chaudhury in 1957  from 433 breast lesions studied by her. This was followed by several reports from different parts of India. A total of 1180 breast lesions were examined (between 1983 and 2003) in the Department of Surgical Oncology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India. Only 8 were diagnosed to have tubercular breast abscess.  In view of recent declaration of tuberculosis being a notifiable disease in India, vide Government of India, Ministry of Health and Family Welfare, Gazette Notification No:Z-28015/2/2012-TB dated 7 th May 2012,  the true incidence of tuberculous mastitis may emerge.
The breast may become infected in a variety of ways,  such as (i) hematogenous, (ii) lymphatic, (iii) spread from contiguous structures, (iv) direct inoculation and (v) ductal infection. Of these, the most accepted view for spread of infection is centripetal lymphatic spread. 
The path of spread of the disease from lungs to breast tissue was traced via tracheobronchial, paratracheal, mediastinal lymph trunk and internal mammary nodes.  According to Cooper's theory, communication between the axillary glands and the breast results in secondary involvement of the breast by retrograde lymphatic extension. Supporting this hypothesis was the fact that axillary node involvement was shown to occur in 50% to 75% of the cases of tubercular mastitis, which was however not observed in our case.
Breast tuberculosis has been reclassified as nodular, disseminated and abscess varieties. The sclerosing type, mastitis obliterans and miliary variety are of historical importance only. 
Mantoux test is usually positive in adults in endemic area for tuberculosis.  It is, therefore of no diagnostic value for breast tuberculosis and stands obsolete today. The modern radiological investigations help in defining the extent of the lesion rather than in diagnosis. Sophisticated radiological tools like mammography, computed tomography (CT scan) and magnetic resonance imaging (MRI) of the breast have been extensively used for the diagnosis of breast tuberculosis but of no avail. The chest X-ray may show evidence of active or healed tuberculous lesion in the lungs in a few cases, and may also reveal clustered calcifications in the axilla suggesting the possibility of lymph node tuberculosis in suspected patients.
The mammogram in breast tuberculosis is of limited value as the findings are often indistinguishable from carcinoma breast. Ultrasonography of the breast is cheap, easily accessible and helps in characterizing the lesion better (especially cystic from solid lesions) without exposure to radiation. 
Though mycobacterial culture remains the gold standard for diagnosis of tuberculosis, the time required and frequent negative results in paucibacillary specimens are important limitations. Polymerase chain reaction (PCR) by gene amplification methods (PCR as well as isothermal) developed for the diagnosis of tuberculosis is highly sensitive especially in culture-negative specimens from paucibacillary forms of disease. A variety of PCR techniques have been developed for detection of specific sequences of Mycobacterium tuberculosis and other mycobacteria. PCR has positivity rates ranging from 40% to 90% in diagnosing tubercular lymphadenitis. 
Tuberculosis of the breast can mimic carcinoma, whereas in the young patients, it can be mistaken for a pyogenic breast abscess, thus labeled "great masquerader" in recognition of its multifaceted presentation.  Clinical examination often fails to differentiate carcinoma breast from tuberculosis, and high index of suspicion is necessary. Factors predictive but not diagnostic of breast tuberculosis include constitutional symptoms, mobile breast lump, multiple sinuses, and an intact nipple and areola  in young, multiparous or lactating females. Nipple retraction, peau d'orange and involvement of axillary lymph nodes are more common in malignancy than in tuberculosis.
The treatment of breast tuberculosis consists of anti-tubercular chemotherapy (ATT) and surgery. ATT is the backbone of treatment of breast tuberculosis.  No specific guidelines are available for the chemotherapy of breast tuberculosis per se. The regimen generally followed in the treatment of breast tuberculosis is similar to that used in pulmonary tuberculosis - a 6-month regimen comprising 2 months of intensive phase treatment (with 4-drug combination) followed by a continuation phase of 4 months (with 2-drug combination). The first line drugs used in this regimen are ethambutol (E) 1200 mg; streptomycin (S) 750 mg, rifampicin (R) 450 mg, isoniazid (H) 600 mg and pyrazinamide (Z) 1500 mg. The Revised National Tuberculosis Control Programme (RNTCP) of India recommends category III regimen (2HRZ/4HR) for less serious forms of extrapulmonary tuberculosis.
| Conclusion|| |
Extrapulmonary tuberculosis occurring in the breast is extremely rare. Breast tuberculosis is uncommon even in countries where the incidence of pulmonary and extrapulmonary tuberculosis is high. In the absence of well-defined clinical features, the true nature of the disease remains obscure and it is often mistaken for carcinoma or pyogenic breast abscess. It also presents a diagnostic problem on radiological and microbiological investigations and thus high index of suspicion acquires an important position. Caseating epitheloid cell granulomas in the tissue samples are diagnostic of tuberculosis. The disease is eminently curable with modern ATT drugs with surgery playing a secondary role in specific clinical setting.
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