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 Table of Contents  
CASE REPORT
Year : 2013  |  Volume : 3  |  Issue : 3  |  Page : 232-234

Primary tuberculosis of the breast presenting as multiple discharging sinuses


1 Department of Surgery, Dr. Dnyandeo Yashwantrao Patil Medical College, Pimpri, Pune, Maharashtra, India
2 Medical Officer, Kamla Nehru Hospital, Pune, Maharashtra, India

Date of Web Publication28-Mar-2014

Correspondence Address:
Sangram Jadhav
Department of Surgery, Dr. Dnyandeo Yashwantrao Patil Medical College, Sant Tukaram Nagar, Pimpri, Pune - 411 036, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-9596.129572

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  Abstract 

Breast tuberculosis is a rare form of tuberculosis (TB). It is mainly classified as primary and secondary forms. Primary form is rare. We are reporting a case of primary TB of the breast with history of breast lump and multiple discharging sinuses. The patient, a 21-year-old unmarried female presented with lump in the breast. She had recurrent fever and multiple discharging sinuses. No positive family history of TB was reported. Primary breast tuberculosis was diagnosed on fine needle aspiration cytology (FNAC). In addition, ZN stain for acid-fast bacilli was positive from the aspirate. The patient was commenced on anti-tuberculosis drugs and at 3-month follow-up the swelling had resolved and the sinuses healed. Breast tuberculosis is a rare disease with non-specific clinical and radiological findings. Misdiagnosis is common as biopsy specimens are pauci-bacillary and investigations such as microscopy and culture are frequently negative. Effort should be made to establish histological diagnosis because breast TB can be safely and completely treated with anti-TB drugs.

Keywords: Breast, extrapulmonary, granulomatous infection, tuberculosis, sinuses


How to cite this article:
Jadhav S, Shinde R. Primary tuberculosis of the breast presenting as multiple discharging sinuses. Arch Int Surg 2013;3:232-4

How to cite this URL:
Jadhav S, Shinde R. Primary tuberculosis of the breast presenting as multiple discharging sinuses. Arch Int Surg [serial online] 2013 [cited 2019 Aug 24];3:232-4. Available from: http://www.archintsurg.org/text.asp?2013/3/3/232/129572


  Introduction Top


Mammary tuberculosis (TB) is a rare form of extrapulmonary TB first described by Sir Astley Cooper in 1829. [1] Although, over one billion people suffer from TB worldwide, mammary tuberculosis is an extremely rare condition. [2] Its prevalence has been estimated to be 0.1% of breast lesions examined histologically. [3] It is uncommon in India. Moreover, the disease is not diagnosed easily because of its physical similarity to carcinoma and bacterial abscesses. [4],[5] The objective of this paper is to report a case of primary TB of the breast, which needs to be clinically diagnosed so that unnecessary surgical intervention is avoided and wound healing can be achieved with medical treatment effectively and without undue diagnostic and therapeutic delay, especially in developing countries like India.


  Case Report Top


A 21-year-old female presented to us with a history of swelling in the right breast for duration of one year. She gave a history of recurrent fever for about one month prior to presentation. There were no other complaints like weight loss, loss of appetite and cough. She was unmarried and no family history of breast cancer or tuberculosis. There was history of discharge from the breast skin in multiple sites since five months with erythema and redness of skin for 15 days.

On physical examination, multiple discharging sinuses were present [Figure 1]. A firm, mobile, mildly tender, diffuse lump about 3 × 5 cm was noted in the right breast. There was no nipple retraction or discharge. Lateral group of axillary lymph nodes measuring 2 × 1 cm in size were palpable.
Figure 1: Multiple discharging sinuses

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Laboratory findings were within normal limits. Chest X-ray was normal. FNAC of the breast lump showed granulomatous mastitis with granulomas, epitheloid cells, and mixed inflammatory cells. The background consisted of necrotic material and ZN stain for acid-fast bacilli (AFB) was positive. FNAC of axillary nodes showed reactive hyperplasia. A diagnosis of primary TB of the breast was made.

She commenced a 6-month course of anti-tubercular drugs comprising of rifampicin, isoniazid, ethambutol, and pyrazinamide for two months followed by rifampicin and isoniazid for another four months. There was healing of the sinuses and a decrease in size of the lump [Figure 2]. The patient responded well to conservative treatment.
Figure 2: Healed sinuses

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  Discussion Top


Breast tuberculosis is a rare entity and may be confused with carcinoma of the breast. Although, its incidence ranges between 0.1% and 0.52%, it is increased in endemic regions. [6] Granulomatous mastitis can occur between 0.025 and 3% of all breast diseases treated surgically. [2],[7] It is mainly classified as primary and secondary forms. Primary form is quite rare. [8] It can spread by three routes: hematogenous, lymphatic, or direct spread. Breast infection is seen more frequently secondary to a tubercular focus from the lungs, pleura, or lymph nodes which may not be detected radiologically or clinically. [9] In our case, breast tuberculosis was the primary focus because there was no evidence of other tubercular focus based on physical or radiological examination nor was there any history of tuberculosis.

In breast TB the most common location of the lump is the central or upper outer quadrant of the breast. The mass may be fluctuant and is usually covered with indurated tissue. As shown in the present case it is usually fixed to the skin and has multiple sinuses. Nipple and skin retraction can also occur, but nipple discharge and pain are not common. Breast tuberculosis is classified into three types on mammography as nodular, disseminated and sclerosing types. The nodular form is the most common type. [9] According to radiological findings, nodular pattern can be mistaken for fibroadenoma or carcinoma. Lesions due to tuberculosis have no specific ultrasonographic findings. They may be heterogenous, hypoechoic and irregularly bordered mass with internal echoes or thick-walled cystic lesions on ultrasonography. [8] In some cases, there may be fistula and thickening of Cooper's ligaments and subcutaneous tissues. FNAC is an important diagnostic tool to diagnose breast tuberculosis. Khanna reported a success rate of 100% in his series. [2] Imaging modalities like mammography or ultrasonography are of limited value as the findings are often indistinguishable from breast carcinoma. [9] TB breast abscess can be diagnosed on mammography as a dense sinus tract connecting an ill-defined breast mass with a localized skin thickening, but Khanna reported these findings in only a few cases. [2] Montoux test is usually positive in adults in endemic areas of tuberculosis, but is not diagnostic.


  Conclusion Top


TB of the breast is an uncommon condition. However, with high index of suspicion it can be diagnosed on clinicopathologic basis. Patients with breast lump should undergo proper investigation including FNAC, which can rule out primary or secondary TB that can be successfully treated without surgery.

 
  References Top

1.Cooper A. Illustrations of the diseases of breast: Part 1. Longman, Rees, Orme, Brown and Green, London; 1829. p. 73.  Back to cited text no. 1
    
2.Khanna R, Prasanna GV, Gupta P, Kumar M, Khanna S, Khanna AK. Mammary Tuberculosis: Report on 52 cases. Postgrad Med J 2002;78:422-4.  Back to cited text no. 2
    
3.Gupta R, Singhal RP, Gupta A, Singhal S, Shahi SR, Singal R. Primary tubercular abscess of the breast--an unusual entity. J Med Life 2012;5:98-100.  Back to cited text no. 3
    
4.Domingo C, Ruiz J, Roig J, Texido A, Aguilar X, Morera J. Tuberculosis of the breast: A rare modern disease. Tubercle 1990;71:221-3.  Back to cited text no. 4
    
5.Green RM, Ormerod LP. Mammary tuberculosis: Rare but still present in the United Kingdom. Int J Tuberc Lung Dis 2000;4:788-90.  Back to cited text no. 5
    
6.Hamit HF, Ragsdale TH. Mammary tuberculosis. J R Soc Med 1982;75:764-5.  Back to cited text no. 6
[PUBMED]    
7.Kalac N, Ozkan B, Bayiz H, Dursun AB, Demirag F. Breast tuberculosis. Breast 2002;11:346-9.  Back to cited text no. 7
    
8.Zandrino F, Monetti F, Gandolfo N. Primary tuberculosis of the breast. A case report. Acta Radiol 2000;41:61-3.  Back to cited text no. 8
    
9.Tewari M, Shukla HS. Breast tuberculosis: Diagnosis, clinical features and management. Indian J Med Res 2005;122:103-10.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2]



 

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Abstract
Introduction
Case Report
Discussion
Conclusion
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