|Year : 2014 | Volume
| Issue : 1 | Page : 62-64
Is primary tuberculosis of breast a forgotten entity? Series of three cases
Dakshayani S Nirhale, Virendra S Athavale, Kunal Kishore, Gaurav G Goenka
Department of General Surgery, Padamashree Dr. D. Y. Patil Medical College, Hospital and Research Center, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pun, India
|Date of Web Publication||10-Dec-2013|
Department of General Surgery, Padamashree Dr. D. Y. Patil Medical College, Hospital and Research Center, Pimpri, Pune - 411018
Source of Support: None, Conflict of Interest: None
The incidence of tuberculosis is high in developing country; primary tuberculosis of breast is extremely rare, 3-4% of all breast lesions. Tuberculosis of breast often mimics breast cancers clinically. We are reporting here three cases of primary tuberculosis of breast presented with painless breast lump. Diagnosis was difficult and made by several parameters in different cases. Made by excision biopsy or the presence of acid-fast bacilli or Tuberculin test or Fine needle aspiration cytology of breast lump depending upon the cases. All the patients responded well to anti-tubercular regimen.
Keywords: Acid-fast bacilli, breast tuberculosis, langhans giant cell.
|How to cite this article:|
Nirhale DS, Athavale VS, Kishore K, Goenka GG. Is primary tuberculosis of breast a forgotten entity? Series of three cases. Med J DY Patil Univ 2014;7:62-4
| Introduction|| |
Tuberculosis bacilli have co-existed with humans as far back as 5000 BC, according to studies of the spine tuberculosis lesions (Pott's disease) from Egyptian mummies. Tuberculosis (TB) continues to be a frequent cause of mortality and morbidity, with an incidence rate of 150 cases per 100,000 people in 2005. Currently, one person becomes newly infected every second worldwide.  Tuberculosis (TB) of breast is extremely rare even in developing countries where pulmonary and other forms of extrapulmonary manifestations of TB are endemic. Breast tissue, along with skeletal muscle and spleen, appears to be relatively resistant to tuberculous infection. Incidence of breast TB accounts for less than 0.1% of all breast lesions in Western countries and 4% of all breast lesions in TB endemic countries. The clinical signs of mammary TB can be insidious and non-specific and often simulate signs of breast carcinoma. Mammary TB usually affects young, multiparous, and lactating women and rarely in male patients. 
| Case Reports|| |
A 23-year-old woman presented with a firm, painless lump 2 × 3 cm in upper outer quadrant of right breast since 3 months. Freely mobile, overlying skin. Nipple areolar complex was normal. No local rise of temperature and axillary lymphadenopathy. No H/o cyclical mastalgia, nipple discharge. No H/o Ca breast, tuberculosis in her family. On admission, ESR- 22, chest X- ray: Normal. Tuberculin test was negative. PCR for TB was negative. Fine Needle Aspiration Cytology: Chronic granulomatous mastits. Negative for AFB and Gram staining. Excision of lump was done [Figure 1]. HPE of removed mass revealed tuberculosis of breast [Figure 2]. Standard anti-tubercular therapy was administered. Post-operative follow up for six months was uneventful.
|Figure 2: Histologic section of a breast nodule of the patient showing epithelioid granuloma (EG) with caseous necrosis (CN), and Langhans-type giant cells (LC) (hematoxylin and eosin-stained, original magnification × 200).|
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A 50-year-old woman presented with a hard lump of 5 × 4 cm in upper outer and retroareolar complex the left breast for three months. Nipple retraction with puckering of the overlying and adjacent skin was present [Figure 3]. No palpable lymph nodes. No family history of carcinoma. Mammography: Spiculated mass lesion in the retroareolar region of the left breast, with nipple retraction and thickening of overlying skin. No microcalcification [Figure 4], though the features were suggestive of malignancy. Ultrasonography- Irregular margins, central necrotic areas with debris and posterior enhancement. USG-guided aspiration revealed purulent discharge. Microbiological examination of the pus showed AFB. Chest X- ray- normal. Standard anti-tubercular therapy was administered. Follow up- patient improved on anti-tubercular treatment.
|Figure 4: Mammography of left breast shows speculated mass lesions with nipple retraction|
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A 45-years-old woman presented with firm lump in the right breast and cystic swelling over the anterior sternum since 2 months. Axillary lymphadenopathy and cervical lymphadenopathy were present [Figure 5]. Freely mobile, overlying skin normal. Nipple areolar complex was normal. No local rise of temperature. No H/o cyclical mastalgia, nipple discharge. H/O tuberculosis in her family present. No H/O Ca breast in family. On admission, ESR- 28, chest X- ray: Normal. Tuberculin test was positive. PCR for TB was negative. Fine Needle Aspiration Cytology from breast lump - Granulomatous mastits and FNAC from anterior chest wall shows- Inflammatory cystic lesion. Negative for AFB and Gram staining. MRI showed- Cold abscess of anterior chest wall. Treatment- Repeated aspiration of cold abscess over anterior chest wall was done. Standard anti-tubercular therapy was administered. Post-operative follow up for six months was uneventful.
|Figure 5: Right breast lump with cystic lesion of anterior chest wall with right infraclavicular lymphadenopathy.|
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| Discussion|| |
Sir Ashley Cooper made the first description of breast tuberculosis in 1829 as the 'scrofulous swelling of the bosom.'  High incidence in endemic area such as India and East Asia - 3 - 4.5% and rare in west - 0.025% to 0.1%. More commonly seen in reproductive age, during lactation and pregnancy. It presents a diagnostic problem on radiological and microbiological investigations. High index of suspicion is needed.  Primary- The term primary tuberculosis of breast is used for tuberculous lesion of breast, in which there is no clinically demonstrable dormant/active lesion of TB found elsewhere in the body. Secondary- When there is a demonstrable focus of tuberculosis elsewhere in the body. The mode of disease transmission is hematogenous and by direct extension after contact with infected material through abrasions of the skin of the lactiferous ducts. ,, Clinical feature of the disease is solitary, ill-defined, unilateral hard lump associated with pain, skin or nipple retraction, nipple discharge, sinus formation, or rarely, peau d'orange. Multiple lumps and bilateral involvement are uncommon. Breast abscess with or without discharging sinuses.  Diagnosis is by Mantoux test - simply demonstrates that at some point of time, the person was exposed to tubercle bacilli. Radiological investigations like mammography, computed tomography scan, and magnetic resonance imaging are of little use. Findings are often indistinguishable from carcinoma breast. Ultrasonography - Differentiate cystic from solid lesions. USG-guided fine needle aspiration decreases the failure rate and obviates the need for multiple punctures.  Tissue diagnosis is confirmed by fine needle aspiration cytology. Seventy three percent cases diagnosed on FNAC when both epitheloid cell granulomas and necrosis are present. AFB may or may not be seen. Histopathology- Obtained by core needle biopsy or excision / incision biopsy almost always confirms diagnosis. Polymerase chain reaction, especially in culture-negative specimen, is positive in 40 - 90% of tubercular lymphadenitis. Role in diagnosis of breast TB is very less reported.  Treatment: Anti-tubercular therapy 6 months. Two months of intensive phase (with four drugs: Ethambutol, pyrazinamide, rifampicin, isoniazid). Four months of continuation phase (with two drugs: Isoniazid and rifampicin). Surgical intervention is required for aspiration of abscesses and excision of sinuses and masses. In resistant cases, simple mastectomy can be performed. Though the primary tuberculosis of breast is said to be rare, it is still seen in endemic areas quite often.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]