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Tuberculosis of Breast-A Case Report with Literature Review

Breast tuberculosis is a rare manifestation of extra-pulmonary localization of the disease which accounts for less than 0.1% of breast conditions in developed countries, but reaches 3-4% in regions where the disease presents with high incidence. It appears mostly in women of reproductive age. We report a 34 year old lady with right breast lump and axillary lymphadenopathy. Smear for tuberculosis and TB tissue cultures were positive and the histopathology repeatedly showed granulomatous inflammation. Treatment with surgery followed by standard anti tubercular drugs was started once mycobacterium tuberculosis was finally cultured from the excised tissue. This case highlights the difficulty in differentiating culture negative tuberculosis from other causes of chronic granulomatous mastitis and the importance of keeping a high index of clinical suspicion. INTRODUCTION Tuberculosis has traditionally been regarded as a pulmonary disorder. Breast tuberculosis is a rare entity, with an incidence of less than 0.1% of all breast lesions in Western countries and 4% of all breast lesions in TB endemic countries. This was first described by Sir Astley Cooper in 1829 as the “scrofulous swelling in the bosom of young women” [1]. High immunity conferred by breast is of significance for low recorded incidence, offering inherent resistance of breast to tuberculosis infection. Tuberculosis mastitis is an uncommon lesion even in countries where the incidence of pulmonary and extra pulmonary TB is still very high. Breast tuberculosis commonly affects women in the reproductive age, usually between 21 and 30 years and can present either as an abscess or as a unilateral, painless breast mass [2]. The disease may be of primary etiology when infection affects breast solely or may result from other foci in the body, which istermed as the secondary tuberculosis of breast. Diagnosis of breast tuberculosis, therefore, remains a challenge for clinicians and requires a high degree of suspicion [3]. Mammography or ultrasonography is unreliable in distinguishing the breast tuberculosis fromcarcinoma because of the variable pattern of presentation of such inflammatory lesion [4]. Histopathology plays pivotal role in the diagnosis. Surgery is reserved only for selected refractory cases. We describe a case of tuberculosis of breast in the present article. CASE REPORT 34 years old lady belonging to poor socioeconomic status presented to our outpatient department with history of painful lump in the right breast for about 1 year. Patient was treated with various antibiotics for several weeks. Her symptoms worsened over a period with increasing pain, swelling and reddish discoloration of skin overlying the breast lump. Patient denied any history of night sweats; evening rise of temperature, respiratory complaints, loss of weight. There was no family history of breast cancer, no personal history of diabetes or recent exposure to a person with tuberculosis. Patient had history of excision biopsy of right axillary lymph node 8 months back which showed granulomatous inflammation with caseous necrosis, gaint cells and epitheloid cells. Patient was treated with anti tubercular drugs for 1 month and discontinued. On examination; she had a firm lump palpable in the lower outer quadrant of the right breast which measured 3 x 2 cms with discharging sinuses over the surface (Figure 1) 2 cms scar was noted in the anterior axillary fold on the right side. Ipsilateral axillary lymph nodes were enlarged. The rest of the physical examination was unremarkable. Blood investigations revealed leukocytosis (15 x 109 /L), elevated CRP (72 mg/L) and elevated ESR (40mm/hr). Serum ACE was normal. Test for HIV was negative. Tissue auto antibodies and ANCA were negative. A chest radiograph and ultrasound abdomen was normal. Ultrasound of the right breast showed hypoechoic lesion of size 3.2 x 2.5 cms in the lower outer quadrant. Mammography showed increased density and coarsened trabeculations but no micro calcifications (Figure 2) MRI was suggestive of advanced right breast carcinoma with lymph nodal involvement or mastitis with reactive lymphadenopathy. FNAC from the breast lump Central Bringing Excellence in Open Access   Nemalidinne Keerthi et al. (2018) Email: JSM Clin Case Rep 6(2): 1146 (2018) 2/3 showed chronic intra lobular mastitis with fibrosis, necrosis and lymphocytic infiltration, did not show any malignant or atypical cells. Direct smear of breast discharge was positive for acid fast bacilli and culture was positive for AFB. Mantoux skin test was 16mm in diameter. Patient underwent excision of breast lump with sinus tract and axillary lymph nodes and was started on ATT after proper counseling and understanding the nature of the disease by her and her parents with daily dose of 300mg isoniazid, 600mg rifampicin, 1500mg pyrazinamide, ethambutol and 10mg pyridoxine for 9 months. Histopathologyof the excised tissue showed eptheloid abscesses with langhan’s gaint cells and caseous necrosis (Figure 3). In subsequent 6 months period no other sinus tract appeared and there was no recurrence of the disease and the total white cell count was 8.3 x 109/L and CRP was 3mg/L. One year after completion of therapy she remained asymptomatic with no recurrence of disease.