|Year : 2022 | Volume
| Issue : 2 | Page : 90-93
'TB or not TB' – A rare case of primary tuberculosis of the breast
Anna Rachel Menezes1, Queennie Elizabeth Jacob1, Sarath Chandra Sistla2
1 Department of Rural Service, St. John's Medical College, Bengaluru, Karnataka, India
2 Department of Surgery, Ashwini Gudalur Adivasi Hospital, Gudalur, Tamil Nadu, India
|Date of Submission||05-Oct-2022|
|Date of Acceptance||22-Nov-2022|
|Date of Web Publication||13-Dec-2022|
Anna Rachel Menezes
St. Ann's Hospital, Elathagiri Road, Elathagiri, Krishnagiri - 635 018, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Tuberculosis (TB) of the breast remains a rare entity that commonly leads to disseminated cold abscesses and the spread of infection, especially in endemic regions like India. Its presentation, a firm nodule, with or without pain leading to ulceration and discharge, mimics various mammary pathologies, including malignancy, mycotic abscesses and granulomatous mastitis, and is, therefore, easily misdiagnosed. We present a case of primary TB of the breast with an abdominal cold abscess in a patient who complained of ulceration in the left breast, having a previous four-year history of a breast lump. Purulent discharge from the ulceration and abscess was positive for TB in a Cartridge-Based Nucleic Acid Amplification Test. She was also incidentally found to have a cold abscess in the superficial fascia in the left iliac fossa. The patient was treated with antitubercular drugs under the National TB Elimination Program. She is currently in her fourth month of treatment and has experienced a resolution of symptoms.
Keywords: Breast tuberculosis, cold abscess, granulomatous mastitis, primary non-pulmonary tuberculosis
|How to cite this article:|
Menezes AR, Jacob QE, Sistla SC. 'TB or not TB' – A rare case of primary tuberculosis of the breast. J Acad Clin Microbiol 2022;24:90-3
| Introduction|| |
Since first described by Sir Astley Cooper in the 19th century as a 'scrofulous swelling in the bosom of young women', tuberculosis (TB) of the breast has been a rare entity with a current prevalence of 3% in endemic regions such as India and Africa., Most cases of breast TB, unlike ours, belong to a category of secondary TB, i.e., reactivation and spread of a latent focus in the lung via haematogenous routes, lymphatic routes or direct extension through the thoracic wall. Primary TB of the breast remains extremely rare, with the most common cause being inoculation through traumatised skin and further spread to the lactiferous ducts and sinuses. Some authors have also opined that all breast TB cases be deemed secondary, even if a primary lesion remains occult.
The diagnosis of breast TB is of supreme importance as it is a strong mimicker of other bacterial abscesses, malignancy, mycotic suppuration of the breast and idiopathic granulomatous mastitis, a rare entity whose prevalence is also on the rise in developing countries.,
| Case Report|| |
History and initial presentation
A 31-year-old married, multiparous, tribal woman came complaining to a rural community hospital in the Gudalur district of South India, with ulceration in the left breast around the nipple-areola complex showing pus discharge. The patient's last child was born five years ago.
Her complaints were associated with a low-grade fever and mild pain around the lesion over the previous three weeks and nausea and headache for the past day. She also gave a history of an irregular menstrual cycle for the past two months. On enquiry, the patient had no history of confirmed pulmonary TB or antitubercular treatment (ATT). She did not have an account of cough or weight loss on arrival.
Four years ago, after the patient last breastfed her child, she had a firm left breast lump, around 3 cm in size. After a biopsy report of the lump suggested idiopathic granulomatous mastitis with abscess, a local government hospital reassured her and treated her with oral analgesics on an outpatient department basis. The lump remained, but the patient had no associated complaints until now.
The patient had no family history of breast carcinoma or TB.
On examination, the left breast nipple-areola complex was oedematous and had multiple 2–3 cm linear ulcerations, which were non-tender and associated with pus discharge [Figure 1]. The patient had no nipple discharge. There was no axillary or cervical lymphadenopathy, and the right breast was normal [Figure 2]. Examination of the abdomen revealed a left iliac fossa swelling that was oblong shaped, 6 cm × 5 cm. It was soft and fluctuant, with a smooth surface and well-defined borders. A cardiovascular system examination revealed a usually split S2 and a flow murmur. There were no other significant findings.
|Figure 1: Image showing the affected left breast. An oedematous and ulcerated left nipple-areola-complex with purulent, serosanguineous discharge. The skin over the breast is wrinkled with multiple areas of inflammatory hypo- and hyperpigmentation|
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On the first day of admission, the patient's haemoglobin level was 10.7g/dL. Her white blood cell count was 8610, with 71% neutrophils and 15% lymphocytes. The erythrocyte sedimentation rate was elevated at 66 mm/hr. Chest X-ray, renal and liver function tests were within standard limits. An HIV antigen test for HIV 1 and 2 was negative.
A Mantoux test was positive. An ultrasound (USG) of her suprapubic swelling revealed a 6 cm × 5 cm hypoechoic cold abscess in the superficial fascial plane. A superficial biopsy of the breast lesion revealed ulceration of the skin with fibropurulent material without any evidence of granulomas or dysplasia. Pus smear acid-fast bacilli (AFB) did not show the presence of AFB, although Cartridge-Based Nucleic Acid Amplification (CB-NAAT) of the pus samples from both cold abscess and breast ulceration were low-grade positive for Mycobacterium tuberculosis nucleic acid [Figure 3] and [Figure 4]. A culture of the samples was not undertaken due to the lack of an appropriate nearby facility. The diagnosis was confirmed with CB-NAAT after a discussion with the concerned microbiologist and pathologist using the possibility that a low-grade positive CB -NAAT report with the absence of bacilli can be seen with a case of paucibacillary TB.
|Figure 3: Biopsy of the ulcerated margins of the lesion. Haematoxylin and eosin-stained image shows a section of nipple skin made of keratinising stratified squamous epithelium with erosions to ulcerations covered with abundant fibrinopurulent material. There is no evidence of granulomas or dysplasia|
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|Figure 4: Biopsy of the discharge. Haematoxylin and eosin-stained image shows mixed inflammatory cell infiltrates with occasional giant cells and the presence of abundant fibrinopurulent material mixed with blood clots|
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CB-NAAT was done at the district TB centre, Gudalur Government hospital, Gudalur, Nilgiris, Tamil Nadu, using a Cepheid GeneXpert System.
After confirming the diagnosis, the patient was started on Antitubercular treatment (ATT). The treatment plan comprised an intensive and continuation phase under the National TB Elimination Programme (NTEP). The intensive phase includes treatment with Isoniazid, Rifampicin, Ethambutol and Pyrazinamide for two months. The continuation phase includes Isoniazid, Rifampicin and Ethambutol for four months. Each NTEP pill consists of a combination of the above drugs and is dispensed on the basis of the patient's weight. The patient belongs to the weight band of 40–54 kg according to the NTEP training modules; hence received three NTEP pills for both intensive and continuation phases. The patient is currently in her third month of the intensive phase. She reports a reduction in pus drainage and a complete resolution of nausea, fever and headache.
| Discussion|| |
TB of the breast, as per available literature, consistent with our case report, usually presents as a firm mass on the central or upper outer quadrant of a single breast in patients mostly with a previous or incidental history of pulmonary TB. Bilateral breast disease is highly sporadic and should warrant further evaluation. The condition is most common among multiparous women who have lactated recently, probably due to denser blood supply and duct dilation during lactation. Cases are also reported among younger men and older women in the 7th–8th decades of life. It is opined that the higher prevalence of TB of the breast in current times, despite intensive control measures, can be attributed to the growing incidence of acquired immunosuppression and increasing resistance to antituberculous drugs.
Breast TB usually presents as a firm swelling with irregular borders, which can adhere to surrounding tissue, ulcerate and form sinuses or fistulae, strongly mimicking malignancy. As with our case, it also closely resembles granulomatous mastitis, often overlooked by physicians, leading to complications such as the formation of disseminated cold abscesses.
After clinical suspicion, a diagnosis can be clinched using microscopic examination and CB-NAAT done on USG-guided Fine Needle Aspiration Cytology (FNAC) samples or pus discharge. USG findings are non-specific and may reveal multiple hypoechoic or cystic lesions with posterior acoustic enhancement. Mammogram findings are categorised into three subtypes: nodular-resembling a fibroadenoma, disseminated-resembling malignancy and sclerosing-involving nipple retraction and fibrous septations. Although magnetic resonance imaging can hint at the extent of the disease, radiological investigations are seldom used to aid in diagnosis due to the lack of specificity.
Treatment is primarily medical, with most patients recovering after six months of standard NTEP ATT, although various reports recommend increasing the treatment duration to 9–18 months, depending on patient response.,, Weight band-based daily dose schedule has been described by the NTEP. Drug resistance is also prevalent; hence, it would be appropriate to do susceptibility tests before the initiation of ATT. Sometimes, minor surgical intervention can be vindicated for biopsying or drainage of an abscess.
| Conclusions|| |
Breast TB is an entity that can be easily underdiagnosed as a benign breast disease such as granulomatous mastitis or fibroadenoma, leading to the spread of infection or overdiagnosed as malignancy leading to unnecessary extortionate procedures. The accurate diagnosis assumes prime importance, especially in developing countries like India, where TB is endemic to utilise resources and decrease caseload effectively. This case report emphasises the fact primary breast TB can be paucibacillary and prompt diagnosis with CB-NAAT, along with swift treatment initiation, can provide significant health-care benefits.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]