TUBERCULOSIS OF THE BREAST – DIAGNOSIS, MANAGEMENT, AND TREATMENT

TUBERCULOSIS OF THE BREAST - DIAGNOSIS, MANAGEMENT, AND TREATMENT

Nasib Al Shibli^*

Department of Surgery, Prince Mutaib Bin Abdulaziz Hospital, Sakaka, Aljouf Region, Saudi Arabia.

ABSTRACT: Tuberculosis is caused by Mycobacterium tuberculosis and affects primarily the lungs. Breast tissue is remarkably resistant to tuberculosis. This is due to fact that it gives infertile environment for survival and multiplication of tubercle bacilli like skeletal muscle and spleen. The breast may become infected by variety of ways e.g. haematogenous, lymphatic, spread from contiguous structures, direct inoculation and ductal infection. The path of spread of disease from lungs to breast tissue was traced via trachea-bronchial, Para tracheal, mediastinal lymph trunk and internal mammary nodes. Scrofulous swelling of the bosom is the description given by Sir Astley Cooper who recorded first ever Breast Tuberculosis. It is usually seen in lactating young multiparous women and presents as lump in the central or upper outer quadrant of breast. It is occasionally mistaken as Carcinoma Breast or Breast Abscess. The overall incidence of tuberculosis Mastitis is reported to be 0.1 % of all breast lesions while in developing countries it constituted approximately 3.0 % of surgically treated breast disease.

Tuberculosis of the breast, Case presentation, Discussion, Conclusion

INTRODUCTION: Tuberculosis is caused by Mycobacterium Tuberculosis and affects primarily the lungs. Breast tissue is remarkably resistant to tuberculosis. This is due to fact that it gives infertile environment for survival and multiplication of tubercle bacilli like skeletal muscle and spleen ¹. The breast may become infected by variety of ways e.g. haematogenous, lymphatic, spread from contiguous structures, direct inoculation and ductal infection ¹. The path of spread of disease from lungs to breast tissue was traced via tracheobronchial, Para tracheal, mediastinal lymph trunk and internal mammary nodes ². Scrofulous swelling of the bosom is the description given by Sir Astley Cooper who recorded first ever Breast Tuberculosis ³.

It is usually seen in lactating young multiparous women and presents as lump in the central or upper outer quadrant of breast ^{4, 5}. It is occasionally mistaken as Carcinoma Breast or Breast Abscess ^{6, 7}. The overall incidence of tuberculosis Mastitis is reported to be 0.1 % of all breast lesions while in developing countries it constituted approximately 3.0 % of surgically treated breast disease ⁸.

Case Presentation: 42 years old Afghani, female patient recently arrived to Saudi Arabia presented to Surgical OPD (outpatient department) with palpable painful lump left breast since three months, with history of lactation since 4 months. Physical examination confirmed a palpable hemispherical lump of about 4 × 4 cm with no overlying skin changes located in upper outer quadrant of left breast. There were no clinical manifestations of the disease in nipple-areola area, or signs of nipple discharge, there were neither redness nor sinuses in overlying skin of the mass. Patient was afebrile. Laboratory Work-up revealed ESR 42 mm/1^st hour, PPD test was positive, Hb=12 gm/dl, other lap chemistry were WNL.

Aspiration yielded frank pus and Ultrasound suggested well-defined lympoechoic mass, multi-loculated in upper half of left breast, Mammography not done as pt refused, CXR was normal. Incision and drainage was done and pus sent for culture and sensitivity and AFB which finally proved negative for growth. Biopsy of wall abscess taken at the time of drainage for histopathology to rule out any malignancy. Wound kept open and left for daily dressing for 2 weeks However, no healing, no improvement seen and discharge continued.

Histopathology showed multinucleated langhans; Giant cells and prominent foamy macrophage, no malignancy seen; suggested granulomatous mastitis with abscess formation and tuberculosis of breast.

FIG. 1: INFLAMMATION IN AND AROUND BREAST LOBULES EXTENDING INTO INTERLOBULAR TISSUE

FIG. 2: GRANULOMA WITH MULTI-NUCLEATED (LANGHANS) GIANT CELL

Patient was started with 4 drugs Anti-Tuberculosis treatment Isoniazid, Rifampicin, Pyrazinamide and Ethambutol, along with local wound care daily. After 3 weeks, discharge started reducing and stopped at 4 weeks of start of treatment. Now patient is on anti TB drugs and breast lesion completely resolved after 6 weeks of therapy and is with follow-up on OPD basis.

FIG. 3: CHRONIC INFLAMMATION WITH MICRO ABSCESSES

FIG. 4: AFTER 13 DAYS FROM I AND D, CASEATING PUS

FIG. 5: AFTER 3 WEEKS TREATMENT OF ATB DRUGS

FIG. 6: COMPLETE HEALING

DISCUSSION: Tuberculosis of the breast comprises 3% of surgically treatable breast condition in India, and uncommon in western population ⁸, actually Afghanistan is considered as high incidence country with rate greater than 40 per 100,000 in 2013 estimated rate was 189 to 100,000 populations.

Tuberculosis of breast is a rare disease mostly because organs or tissues like the breast, skeletal muscle and spleen are more resistant to infection, making the survival and multiplication of tubercle bacilli difficult ^{9, 10}. Because of increased blood supply to breasts and dilated ducts in lactating women, they are at higher risk and more vulnerable to infection ⁵.

There are three clinical varieties of mammary tuberculosis; nodular, disseminating and sclerosing ¹¹. Tuberculosis mastitis is mostly unilateral and rare in male patients however, an immuno-deficiency state like HIV increase the risk ⁶, patients has non-reactive to HIV screening. The commonest presentation is that of lump, painful or not and most often located in central or upper outer quadrant of the breast ^{12, 13} as it is seen in our patient.

Various tests are useful in diagnosis and evaluation of patient. Manteaux test does not help much for definitive diagnosis. At Ultrasonography; hypo echoic mass may be seen in 60% of patients and one may identify fistula or sinus tract in cases of tuberculosis mastitis ^9-13.

Computerized tomography or MR may help to extension of disease beyond breast and gold standard for diagnosis of breast tuberculosis in detection of mastitis tuberculosis on Z. N. staining or by culture ⁹ but they have own limitations like false negative results, but CT scan and MRI not done. Finally, histopathology of lesion identifies granulomatous inflammation with Caseation, necrosis and langhan’s giant cells and it contributed to diagnosis in majority of cases.

The differential diagnosis is cancer breast, fat necrosis, plasma cell, mastitis, idiopathic granulomatous mastitis and infections like actinomycosis ^{4, 9, 15, 16}. Medical treatment of TB breast generally is similar to that used in active pulmonary tuberculosis, consisting of four drug therapy of INH, RIFA, pyrazinamide and Ethambutol for the initial 2 months of treatment and completed by 4 months of only INH and RIFA. Surgical intervention is reserved for drainage /aspiration of abscess, removal of residual sinuses and masses ¹⁷. In refractory case, simple mastectomy mat be considered.

CONCLUSION: Extra pulmonary tuberculosis occurring in breast is rare. It is often mistaken for cancer or pyogenic breast abscess because of nuclear clinical features. High index of suspicion is required, as radiological and microbiological tool often unyielding. Tissue diagnosis is helping to treat tuberculosis breast in surgical practice. Anti-TB drugs play vital role for cure of disease and surgery has its role to drain abscesses, take tissue for diagnosis and simple mastectomy in refractory cases which are rare.

ACKNOWLEDGEMENT: Nil.

CONFLICT OF INTEREST: None declared.

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    How to cite this article:

    Al-shibli N: Tuberculosis of the breast - diagnosis, management, and treatment. Int J Pharm Sci Res 2017; 8(9): 3962-65.doi: 10.13040/ IJPSR.0975-8232.8(9).3962-65.

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