|Year : 2013 | Volume
| Issue : 2 | Page : 206-207
Tubercular breast abscess
Pradeep S Jadhav, Pradhan M Pagaro, Anjali Verma, Anjali Deshpande
Department of Pathology, Padmashree Dr. D. Y. Patil Medical College, Hospital & Research Centre, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune, Maharashtra, India
|Date of Web Publication||10-Apr-2013|
Pradeep S Jadhav
Sai-Vijay Apartment, Sector-28, Plot-295, Pradhikaran Nigdi, Pune, Maharashtra
Source of Support: None, Conflict of Interest: None
Tubercular breast abscess is a rare clinical entity and affects women from mainly the Indian subcontinent. It often mimics breast carcinoma and pyogenic breast abscess clinically. Routine laboratory investigations are not helpful in the diagnosis. Fine needle aspiration cytology (FNAC) or biopsy is essential for diagnosis, and tuberculous culture when positive may be very useful to start antitubercular treatment.
Keywords: Breast, fine needle aspiration cytology, tuberculosis
|How to cite this article:|
Jadhav PS, Pagaro PM, Verma A, Deshpande A. Tubercular breast abscess. Med J DY Patil Univ 2013;6:206-7
| Introduction|| |
Tuberculosis is a worldwide problem. Approximately 8-10 million new cases are diagnosed and 2-3 million deaths occur from tuberculosis every year.  Extrapulmonary tuberculosis is on the rise the world over. Tuberculosis of breast is rare with incidence varying from 3% to 4.5% in India.  Because of its multifaceted presentation, clinicians may confuse tuberculous mastitis with either breast abscess or carcinoma. First case of mammary tuberculosis was described by Sir Astley Copper in 1829 and he called it "scrofulous swelling of bosom."  Fine needle aspiration cytology (FNAC) is very useful in the diagnosis of breast lump and definitive therapy can be started on the basis of FNAC results. 
| Case Report|| |
A 35-year-old female patient was admitted with history of right breast lump since 1 month. There was pain in the swelling since 8 days and history of nipple discharge since 1 week. There was no history of weight loss and cough with expectoration. On general and physical examination, no abnormality was detected. Examination of breast revealed a tender, ill-defined, irregular, and firm to hard breast lump of size 4 × 3 cm adherent to the breast tissue. Axillary lymph nodes were palpable. Respiratory system examination was unremarkable. Clinical diagnosis of ?carcinoma breast was given.
Her routine lab investigations revealed leukocytosis and neutrophilia. Her erythrocyte sedimentation rate (ESR) was 49 at the end of 1 st hour. Chest radiograph was unremarkable. USG of breast revealed a 4 × 3 cm hypoechoic lesion seen in the retroareolar area. The swelling had ill-defined echogenic capsule and the underlying pectoralis muscle was normal. Axillary lymphadenopathy was noted in anterior axillary fold. Impression of chronic abscess was given.
FNAC of breast lump was done. Grossly pus was aspirated. Smears were stained with Leishman stain and Ziehl Neelsen (ZN) stain.
On microscopy the smears showed nonspecific inflammatory findings in the form of lots of neutrophils and macrophages against a necrotic background [Figure 1]. There was no evidence of epithelioid cells and Langhan's type of giant cells. ZN stain was strongly positive for acid-fast bacilli (AFB) [Figure 2]. So, the diagnosis of tubercular breast abscess was offered.
|Figure 1: FNAC smear shows necrotic material, many neutrophils, and few macrophages (Leishman stain, × 400)|
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The pus was sent to microbiology department for routine and AFB culture. Routine culture did not show any growth. The automatic MB Bactec culture revealed growth of Mycobacterium tuberculosis.
| Discussion|| |
Tuberculosis of the mammary gland is a rare disorder often mistaken for other benign and malignant lesions of the breast. Breast and skin are rare sites of extrapulmonary tuberculosis. Tuberculous mastitis is commonly seen in females of reproductive age group, especially during lactation period since the lactating breast is more vascular and susceptible to trauma. 
Primary tuberculous infection of the breast may occur through skin abrasions or through duct openings of the nipple. It is generally believed that infection of the breast is secondary to tuberculous focus elsewhere in the body, which may not be clinically or radiologically apparent. Involvement in such cases can be hematogenous or by retrograde lymphatic extension. 
Breast tuberculosis was originally classified by Makennn et al. into five categories: 
- Acute miliary type: rare due to blood-borne infection in miliary tuberculosis
- Nodular type: the most common type which presents as a localized lump with or without sinuses in one quadrant of the breast
- Disseminated type: involving the entire breast with multiple sinuses
- Sclerosing type: minimal caseation and extensive hyalinization of the stroma
- Tuberculous mastitis obliterans: a rare form due to intraductal infection with fibrosis and obliteration of the ductal system
In our case, nodular type of breast tuberculosis was seen. The diagnosis of TB can be established by demonstrating AFB in the aspirate. However, the demonstration of AFB from the lesion is usually difficult.  But in our case, large numbers of AFB were seen on the ZN smear. It has been stated that in endemic countries, the findings of epithelioid granulomas on FNAC warrant empirical treatment for the tuberculosis even in the absence of positive AFB and without culture results. ,
The significance of breast tuberculosis is due to its rare occurrence and mistaken identity with breast cancer and pyogenic breast abscess. With spread of AIDS worldwide and re-emergence of tuberculosis in developing countries like India, breast may become a major site of extrapulmonary tuberculosis, next to lymph node.
| Conclusion|| |
Despite the recent surge in the popularity of core biopsy, FNAC done by expert hands is an extremely accurate test with very high specificity and sensitivity. The definitive diagnosis can be established by a combination of cytolomorphological features, microbiological studies, and high index of suspicion.
| References|| |
|1.||Miller B, Schieffelbein C. Tuberculosis. Bull World Health Organ 1998;76(suppl 2):141-3. |
|2.||Shinde SR, Chandowarkar RY, Deshmukh SP. Tuberculosis of the breast Masquerading as carcinoma: A study of 100 patients. World J Surg 1995;19:379-81. |
|3.||Hamit HF, Ragdale TH. Mammary tuberculosis. JR Soc Med 1982;75:764-5. |
|4.||Verma K, Kapil K. The role of fine needle aspiration cytology of breast lumps in the management of patients. Indian J Med Res 1989;90:135-9. |
|5.||Tauro LF, Martis JS, George C, Kamath A, Lobo G, Hegde BR. Tuberculous mastitis presenting as breast abscess. Oman Med J 2011;26:53-5. |
|6.||Kishor B, Khan P, Gupta RJ, Bisht SP. Fine needle aspiration cytology in the diagnosis of inflammatory lesions of breast with emphasis on tuberculous mastitis. J Cytol 2007;24:155-6. |
|7.||Kakkar S, Kapila K, Sing MK, Verma K. Tuberculosis of the breast. A cytomorphological study. Acta Cytol 2000;44:292-6. |
|8.||Tewari M, Shukla HS. Breast tuberculosis; diagnosis, clinical features & management. Indian J Med Res 2005;122:103-10. |
[Figure 1], [Figure 2]