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BREAST Table of Contents   
Year : 1999  |  Volume : 9  |  Issue : 3  |  Page : 127-132
Pictorial essay :Tuberculosis of the breast


Department of Radiological Imaging and N.M.R. Research Centre Institute of Nuclear Medicine & Allied Sciences, Delhi-110054, India

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Keywords: Tuberculosis, Breast

How to cite this article:
Popli MB. Pictorial essay :Tuberculosis of the breast. Indian J Radiol Imaging 1999;9:127-32

How to cite this URL:
Popli MB. Pictorial essay :Tuberculosis of the breast. Indian J Radiol Imaging [serial online] 1999 [cited 2019 Nov 19];9:127-32. Available from: http://www.ijri.org/text.asp?1999/9/3/127/28318
Tuberculosis of the breast is a rare disease. It is uncommon even in countries where the incidence of pulmonary and extrapulmonary tuberculosis is high. Not having well-defined clinical features, the true nature of the disease remains obscure and it is mistaken for carcinoma or pyogenic inflammatory disease of the breast. It also presents a diagnostic problem on mammography and ultrasound. The diagnostic criteria are the presence of granulomatous infiltrates and/or tubercles with central caseation, seen on histology or bacteriological culture of the aspirate. The disease is rarely bilateral and sometimes occurs along with breast cancer. Presented here are seven patients who clinically and radiologically mimicked carcinoma or inflammatory lesions of the breast.


   Case Reports Top


Case 1:

A forty-six years old woman presented with multiple discharging sinuses of the right breast and a palpable lump. According to the patient, the lump had been present for the past six to seven months and the sinuses had developed recently. On physical examination, the right breast was very tender and a diffuse, irregular mass was felt, mainly involving the lower quadrants. There was tethering and discoloration of the overlying skin with multiple sinuses discharging dirty white fluid on pressure [Figure - 1]a. The mass also appeared to be fixed to the chest wall. A few enlarged nodes were also palpated in the right axilia. The left breast was clinically normal. Mammography revealed large, irregularly marginated, dense areas in the inferior and lateral quadrant of the right breast [Figure - 1]b,c. On sonomammography, the normal echopattern was lost and an ill-defined mass of mixed echogenicity was seen in the lower half of the right breast [Figure - 1]c. Fine needle aspiration biopsy (FNAC) of the lesion revealed a granulomatous inflammatory process and M. tuberculosis. The chest radiograph of the patient was normal. There was no family history of tuberculosis. Except for the mildly raised ESR, no other systemic signs and symptoms of tuberculosis were seen.

Case 2:

A sixty-eight years old woman reported a mass in the upper and outer quadrant of the left breast of a few days duration. Clinically, the mass measured 4 x 2.5 x 2cm. and was fixed to the skin. No axillary nodes were palpated. Mammography revealed a spiculated mass and a diagnosis of malignancy was suggested [Figure - 2]a. On USm a mass of mixed echogenicity was seen [Figure - 2]b. Microscopic examination revealed chronic granulomatous inflammation with areas of central necrosis suggestive of tuberculosis.

Case 3:

A thirty-eight years old woman complained of a lump in the upper and outer quadrant of the right breast, which had been present for six to seven months. Clinically, the lump was tender and firm to hard with restricted mobility, measuring 3.6 x 2.5 x 3 cm. Axillary nodes were not palpated. Mammography revealed a well defined, lobulated indeterminate mass. US of the breast showed a complex cystic mass [Figure - 3]. The aspirate was positive for AFB.

Case 4:

A forty-five years old woman complained of tenderness and hardness of the right breast. The patient gave a history of pulmonary tuberculosis, which was treated a few years ago. Clinically, the right breast was smaller and firm to hard as compared to the left. On mammography, diffuse increased density was seen in the right breast [Figure - 4]a,b. Sonography revealed increased echogenicity of the right side as compared to the left [Figure - 4]c. Aspiration cytology was inadequate. A diagnosis of tuberculous mastitis was made after incision biopsy.

Case 5:

A patient aged 33 years presented with a two-months history of a lump in the left breast slowly increasing in size. A vague lump was palpable below the region of the areola. Mammography showed increased density [Figure - 5]a,b. Because of the dense parenchyma the lesion was not well-circumscribed. On US, a predominantly hypoechoic mass was seen with an ill-defined border [Figure - 5]b. Histopathology confirmed the diagnosis of tuberculosis

Case 6:

A sixty-six years old woman came with a history of retraction of the left nipple which had gradually increased over a period of six weeks. A small lump was palpable in the parenchyma but could not be identified on the mammogram [Figure - 6]. On histology a tentative diagnosis of granulomatous mastitis probably tuberculous in origin was suggested.

Case 7:

A twenty-two years old woman presented with a lump in the right breast in the upper and outer quadrant. The breast was very tender. The overlying skin was discoloured and indurated. A tentative diagnosis of breast abscess was made and the patient was given a course of antibiotics. US revealed a mass of mixed echogenicity interspersed with areas of necrosis, with ill-defined margins [Figure - 7]. FNAC was inconclusive and the procedure was repeated. The aspirate was found to be positive for AFB.


   Discussion Top


Tuberculosis of the breast was first described by Cooper in 1829 as the 'scrofulous swelling of the bosom' [1]. In 1944, Klossner reported 50 cases of tuberculosis of the breast in women, out of 75,000 with lung involvement [2]. Only a few clinical reports have been reported from the Indian subcontinent in spite of the high prevalence of other forms of tuberculosis in this region [3],[4],[5],[6],[7],[8]. The disease has been reported in the 20-50 years age group.

Four of our patients were above 45 years of age and in the risk group for breast cancer and clinically and radiologically, a provisional diagnosis of breast cancer was made. Tuberculosis was diagnosed only on cytology/histopathology. In three of the five patients who presented with a lump, the site was the upper and outer quadrant, which is also the commonest site for carcinoma of the breast [9]. Therefore mammary tuberculosis though occurring less frequently than other breast lesions merits recognition, as it is a disease which confuses the surgeon, radiologist and pathologist alike.

Breast tuberculosis may be primary where the breast lesion is the only manifestation of the disease or it may be secondary in which a focus of tuberculosis has already been diagnosed elsewhere in the body and the disease appears in the breast at a later stage [9]. The method of spread to the breast is by the hematogenous or lymphatic routes or by direct extension from adjacent tissues [11].

The disease presents in three forms: nodular, diffuse and sclerosing. The nodular form is characterised by a slow growing caseating lesion and mammographically presents as a dense round area with indistinct margins. The diffuse form consists of multiple, intercommunicating foci of tuberculosis within the breast, which may caseate leading to ulceration and numerous discharging sinuses. The skin may be thickened, with a tense and tender breast. In addition to the breast lesion, the axillary lymph nodes are frequently affected. Radiographs show a dense breast and thickened skin. In the sclerosing form, excessive fibrosis rather than caseation is the dominating feature. Progress is slow and suppuration is rarely seen. The entire breast becomes hard because of the dense fibrous tissue and the nipple gets retracted. Increased density of the gland is seen on mammography. All the three forms of the disease are indistinguishable from breast cancer clinically as well as on mammography.

No sonographic details of patients with breast tuberculosis are available. In the limited number of patients that we studied, we found that the nodular form of the disease was more common and the lesions were either hypoechoic with ill-defined margins or complex cystic masses [Figure - 2]b, [Figure - 3]b, [Figure - 5]b, [Figure - 7]. In cases of diffuse tuberculosis, ill-defined hypoechoic masses were seen [Figure - 1]c. In patients with sclerosing tuberculosis, increased echogenicity of the breast parenchyma was seen with no definite mass [Figure - 4]b. Sonography helps in characterizing the lesion better, especially in young patients with dense parenchyma. US guided FNAC decreases the failure rate and obviates the need for multiple punctures.

To conclude, clinical and radiological signs are unreliable in tuberculosis of the breast. A diagnosis of mammary tuberculosis should be made in a patient with or without a past history of tuberculosis, if the patient presents clinically with a lump and radiologically, on mammography and US, with an indeterminate mass. Investigations should be undertaken to exclude tuberculosis in view of the high prevalence of this disease in our country. Also in the Indian context multiple chronic discharging sinuses suggest tuberculosis.


   Acknowledgement Top


We thank Mr S R Sharma for the excellent photographs.[12]

 
   References Top

1.Cooper A. Illustrations of the diseases of the breast. London: Longman, Rees and Co. 1829.   Back to cited text no. 1    
2.Klossner AR. Uber die Brustdrusentuberculose. Eine pathologisch-anatomische und klinische studie. Acta Chir Scand 1944; 90 (Suppl 85): 1-181.   Back to cited text no. 2    
3.Banerjee A, Green B, Burke M. Tuberculous and granulomatous mastitis. Practitioner 1989; 233: 754-757.   Back to cited text no. 3  [PUBMED]  
4.Tan KK, Tan TH. Tuberculosis of the breast. Singapore Med J 1988; 29: 271-275.   Back to cited text no. 4  [PUBMED]  
5.Sheikh MY, Rana TA, Islam MU. Tuberculous mastitis mimicking malignancy: a case report with review of literature. JPMA 1993; 43: 122-123.   Back to cited text no. 5  [PUBMED]  
6.Bahadur P, Aurora AL, Sibbal RM, Prabhu SS. Tuberculosis of the mammary gland. JIMA 1983; 21: 67-80.   Back to cited text no. 6    
7.Rangabhashyam N, Gnanaprakasm D, Krishnaraj B et al . Spectrum of benign breast lesions in Madras. J R Coll Surg Edinb 1983; 28: 369-373.   Back to cited text no. 7    
8.Sharma AK, Sree S, Misra SK. Tuberculous mastitis: a pragmatic approach to its management. Aust N Z J Surg 1993; 63: 263-265.   Back to cited text no. 8    
9.The Breast. In: AJ Hardinge Rains, Charles V Mann, eds. Bailey and Love's short practice of surgery, 20th ed. London: HK Lewis and Co. Ltd, 1989: 712-739.   Back to cited text no. 9    
10.Wilson JP, Chapman SW. Tubercular mastitis. Chest 1990; 98: 1505-1509.   Back to cited text no. 10  [PUBMED]  
11.Laszic Tabar, Karoly Kett, Aspad Nemeth. Tuberculosis of the breast. Radiology 1976; 118: 587-589.   Back to cited text no. 11    
12.D'Orsi CJ, Feldhaus L, Sonnefeld M. Unusual lesions of the breast. Radiol Clin N Am 1983; 21: 67-80.  Back to cited text no. 12    

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Correspondence Address:
Manju Bala Popli
127-B/AC-2, Shalimar Bagh, Delhi 110 052
India
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    Figures

[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6], [Figure - 7]

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