Case Report

Mammary Tuberculosis in a Young Female Presenting asVoluminous Abscess - A Case ReportSurg Capt S C Patra (Retd)", Dr. Swapnil Tople"

Introduction

Mammary Tuberculosis is an extremely rare entityand gain great significance due to its mistaken identitywith chronic pyogenic abscess and breast cancer. Itwas discovered for the first time by Cooper in 1829(l). It is scarcely reported even in countries with ahigh incidence of tuberculosis infection. This isexplained by a noticeable resistance of the mammarytissue to the mycobacterium tuberculosis (2).Mammary tuberculosis presents a diagnostic problemon radiological and microbiological investigations.Diagnosis of breast tuberculosis therefore remains achallenge for the clinician. Anti-tubercular therapy withor without minimal surgical intervention forms themainstay of treatment. We report a case of mammarytuberculosis in a young female presenting as avoluminous tubercular abscess and mimicking theclinical form of a pyogenic breast abscess.

Case ReportA 18 years old female presented with a rapidly

growing lump in the left breast of 2 weeks duration.(Fig 1) -

Fig 1: Clinical presentation of tubercular abscess of left breast

The patient had a past history of pulmonarytuberculosis and had taken a complete course of anti-tubercular therapy. Physical examination revealed anafebrile and normotensive patient with no pallor,icterus or generalized lymphadenopathy. Breastexamination confirmed a 15 x 14 x 4 cm lump involvingthe left breast. There was no local warmth ortenderness. The lump had a smooth surface with well-defmed margins and was variegated in consistency.It was neither fixed to the skin nor to the underlyingmuscle. Left nipple was retracted and the overlyingskin was stretched with few visible dilated veins. Therewas a palpable 1.5 em single, firm, non-tender andmobile.axillary lymph node.

A clinical diagnosis of mammary abscess wasmade. Laboratory work up revealed raised ESR withnormal leucocyte count and normal liver and renalfunction test results. Chest X-ray was normal. Ultrasonography (USG) breast revealed evidence of leftbreast abscess with thick pyogenic debris and areactive axillary lymph node in left axilla.Mammography revealed evidence of a well-defmedmass lesion with liquid content. Fine needle aspirationcytology (FNAC) of axillary lymph node wasreported as reactive lymphadenitis. Diagnosticaspiration of left breast mass was undertaken whichrevealed thick pus and was sent for microscopy,culture and Z-N staining. Gram staining revealedStaphylococcus aureus for which the patient wastreated with amoxicillin and clavulanate potassiumempirically. Considering the sonography, aspirationand Gram staining report, incision and drainage ofthe breast abscess was done and approximately 300ml of pus drained which was sent for microscopy,

"Professor, "Senior Resident, Department of General Surgery, ESI Post Graduate Institute Medical Science &Research, Mahatma Gandhi Memorial Hospital, Parel, Mumbai-4000l2."Corresponding author: Email-drscpatra@gmail.com. Mob: (+91)9869859992

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culture and Z-N staining. Breast tissue scraping fromabscess cavity wall was sent for histo-pathologicalexamination. Z-N staining revealed Acid fast bacilli.Patient received CAT II AKT to which she respondedwell. Follow- up at 2 months revealed asymptomatically better patient with a well healedwound.

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DiscussionIn developing countries like India where

Tuberculosis (TB) is endemic, TB of the breastaccounts for only 3% of treatable breast conditions[3]. Tuberculosis is caused by Mycobacteriumtuberculosis and affects primarily the lungs. BreastTB could be primary when breast lesion is the onlymanifestation ofTB or secondary when demonstrableTB lesion is present elsewhere in the body (4)However, it is now increasingly accepted that breastTB is almost invariably secondary to a lesionelsewhere in the body (5).

The breast may be infected by several ways. Theroute of spread includes haematogenous, lymphatic,from contiguous structures, direct inoculation, andductal infection. Of these the most accepted view ofspread of infection is centripetal lymphatic spread,from lungs to breast tissue, via the tracheobronchial,para-tracheal, mediastinal lymph trunk and internalmammary nodes. Infection through skin abrasions,through main ducts of nipple or retrograde spreadfrom axillary lymph node may result in formation ofa mammary abscess.

Mammary tuberculosis commonly affects youngwomen of reproductive age group. It is relativelyuncommon in pre-pubescent females and elderlywomen. Pregnant and lactating women arepredisposed to trauma making it more susceptible totuberculatinfection. Breast tuberculosis is rare inmales.

Mammary tuberculosis' usually presents as aunilateral disease. Bilateral involvement is uncommon«3 %). Lump in breast with or without axillary lymphnodes is the most common presentation. Mammarytuberculosis may present as peau d'orangeappearance of skin, ulcers, purulent nipple discharge,and breast abscess with or without discharging sinus(5).

MT was recently classified in to 3 categories byTewari & Shukla (2) : nodulocaseous tubercular

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mastitis, disseminated/confluent tubercular mastitis,and tubercular breast abscess. Our case falls in thelast category. Various test are useful in the diagnosisand evaluation of patients with mammary tuberculosis.Mantoux test does not offer any defmitive diagnosis,but confirms exposure of patient to tubercular bacilli.Chest X -ray may show evidence of active or healedtuberculous lesions in the lung. Mammography, is nothelpful especially in young women, due to high densityof breast tissue where as in elderly women,mammography findings are generally indistinguishablefrom Breast Carcinoma. USG generally shows ahypoecheoic lesion in 60% of patients and it maysometimes identify a sinus tract in tuberculous mastitis.FNAC may not be able to detect the responsiblepathogen itself, but is helpful in detecting the presenceof epitheloid cell granulomas and necrosis, leading toa defmitive diagnosis in up to 73% of cases of\mammary tuberculosis (7). In tubercular mammaryabscess, the only essential element to confmn thediagnosis is histopathological test of the sampleobtained after the surgery, as in our case, or biopsyof abscess wall. CT and MRI breast are used toevaluate the extension of the lesion beyond the breast,principally towards the thoracic wall. The goldstandard for diagnosis of breast tuberculosis isdetection of Mycobacteriun tuberculosis by Z-Nstaining or by culture (4). Histo-chemistry, howeveris not practical and culture of Mycobacteriuntuberculosis has limitations due to delay in obtainingthe final result and possibility of false negative resultsin pauci-bacillary samples. PCR is highly sensitivefor diagnosis of mammary tuberculosis. It is especiallyrecommended in cases with negative culture results.Histopathology of the lesion identifies a chronicgranulomatous inflammation with caseous necrosisand Langhan's type giant cells, contributing todiagnosis in majority of cases. The principaldifferential diagnosis of mammary tuberculosis isbreast carcinoma and other conditions such as fattynecrosis, plasma cell mastitis, peri-areolar abscess,idiopathic granulomatous mastitis, actinomycisis andblastomycosis are to be considered. (4)

Anti-tuberculous therapy with 2HRZE+4HRforms the mainstay of treatment (5). Surgicalintervention is required for aspiration or drainage ofabscesses or excision of sinuses or masses. Simplemastectomy, most often without axillary lymph nodedissection is reserved for. cases with extensive

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disease, causing a large painful ulcerated massinvolving entire breast. (6)

ConclusionA diagnosis of mammary tuberculosis should be

made in a patient with or without a past history oftuberculosis, if the patient presents clinically with alump and imaging studies like mammography andUSG shows an indeterminate mass. This case reportconcludes that clinical and radiological signs areunreliable and mammary tuberculosis has to beconsidered in the differential diagnosis of breastlesions, especially in breast abscesses with or withoutdischarging sinuses and more so if the patient belongsto the high-risk population or lives in an endemicregion.

How to cite the articlePatra S C, Dr Tople Swapnil. Mammary Tuberculosis in a

Young Female Presenting as Voluminous Abscess. J. MarineMedical Society, 2014, 16 (1): 55-57.

Source of supportNil

Jour. Marine Medical Society, 2014, Vol. 16, No.1

Conflicts of interestAll authors have none to Declare.

References1. Cooper: Illustrations of the Diseases of the Breast. Part 1.

London: Longman, Rees, Orme, Brown, and Green 1829:73.

2. Tewari M., Shukla H.S.: Breast tuberculosis: Diagnosis,clinical features & management. Indian J Med Res, 2005,122: 103-110.

3. Khanna R, Prasanna GV, Gupta P, Kumar M, Khanna S,Khanna AK: Mammary tuberculosis: report on 52 cases.Postgrad Med J 2002; 78: 422-424.

4. Spyridon M, Dionysia L, et al. Breast tuberculosis:Diagnosis, management and treatment. Int J Surg Case Rep.2012; 3(11) : 548-550.

5. Surendra K Sharma, Alladi Mohan et al. Tuberculosis, Secondedition 2009:29;434-40.

6. Imtiaz W, AliM.L., et al. Secondary Tuberculosis of Breast:Case Report.ISRN Surg, Vo12011, Article lD 52936j1,.

7. Kakkar S., KapilaK., Singh M.K., VermaK. : Tuberculosisof the breast. A cytomorphologic study. Acta Cytol,2000,44: 292-296.

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