|Year : 2011 | Volume
| Issue : 1 | Page : 20-23
Tuberculous mastitis: Not an infrequent malady
Sagar C Mhetre1, Chandrakanth V Rathod1, Trupti V Katti1, Y Chennappa2, Anand S Ananthrao1
1 Department of Pathology, Navodaya Medical College, Raichur, Karnataka, India
2 Department of Pathology,Santiram Medical College, Nandyal, Kurnool, Andhra Pradesh, India
|Date of Web Publication||24-Aug-2011|
Sagar C Mhetre
Department of Pathology, Navodya Medical College, Mantralayam Road, Raichur - 584103, Karnataka
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background and Objectives : Tuberculosis of the breast, surprisingly, is not an infrequent malady as presumed in this highly overcrowded country, India, and therefore, curiosity arose to investigate these cases in further detail.
Materials and Methods : The patients' records were obtained from the Surgical Pathology Section of the Department of Pathology, Santhiram Medical College, Nandyal, Dist., Kurnool (AP), India, from 2005 to 2010. The pathological material and clinical history from all histopathologically diagnosed cases of breast tuberculosis were then re-examined independently by us. Ziehl Neelson staining was done to demonstrate mycobacterium tuberculous bacilli.
Results : Eleven cases of tuberculosis of the breast encountered over a five-year period, accounted for 4.1% of all breast lesions. All patients were females. Most of the patients (63.6%) were in the 26 to 35 years age group. Five cases (45.4%) were lactating at the time of presentation. Only two cases were diagnosed as tuberculous mastitis on the basis of a breast lump, with chronic discharging sinuses. In two cases, the breast lump simulated carcinoma.
Conclusion : Tuberculous mastitis occurs more frequently than is supposed. The predisposing factors for its development are reproductive age group and lactation. As this lesion can mimic carcinoma breast, all breast lumps must be diagnosed histopathologically before radical treatment is undertaken, to avoid needless mastectomies.
Keywords: Breast, chronic mastitis, histopathology, tuberculosis
|How to cite this article:|
Mhetre SC, Rathod CV, Katti TV, Chennappa Y, Ananthrao AS. Tuberculous mastitis: Not an infrequent malady. Ann Nigerian Med 2011;5:20-3
| Introduction|| |
The breast was thought to be immune to tuberculosis until the epical description of the first case by Sir Astley Cooper in 1829.  It is extremely rare in the industrialized world, but is commonly encountered in developing countries like India.  Only 28 cases of mammary tuberculosis have been reported in Japan over a 15-year period.  The overall incidence of tuberculosis mastitis is reported to be 0.1% among all breast lesions in developed countries, while in developing countries it constitutes approximately 3% of the surgically treated breast diseases.  In the present study, we have reviewed our experience of five years with this disease, and surprisingly have found that it is not an infrequent malady, as presumed, so curiosity arose to investigate these cases in detail, focusing on their epidemiology, clinical presentation, and pathology.
| Materials and Methods|| |
The patient records of all breast biopsies were obtained from the Surgical Pathology Section of Department of Pathology, Santhriram Medical College, Nandyal, District, Kurnool (AP), India, from 1 st July 2005 to 30 th June 2010. We identified all histopathologically diagnosed breast tuberculosis cases. We retrieved and reviewed the FNAC slides; tru-cut biopsy, and excision biopsy blocks and slides, along with the clinical history forms of all the cases. In some cases fresh blocks from resected breasts were reviewed for confirmation and additional information. Ziehl Neelson staining was done to demonstrate mycobacterium tuberculous bacilli.
| Results|| |
During the period under review, a total of 267 breast tissues were processed in the histopathology section and out of these, 11 (4.1%) were diagnosed as tuberculous mastitis. All the women were married, and their age ranged from 25 to 49 years, with most patients (63.6%) in the 26 to 35 year range [Table 1].
Five patients were lactating (45.4%) at the time of diagnosis, only one breast was found to be involved, and it was usually the right one (81.8%)
Clinical presentation and surgical procedures done on these patients is shown in [Table 2].
Diagnosis of tuberculous mastitis was suspected clinically only in two (18.1%) cases. These cases presented with a lump in the breast, with chronic discharging sinuses. Associated lymphadenopathy was found in four (36.3%) cases on the same side. Constitutional symptoms of tuberculosis in the form of fever, weight loss, night sweats or failing general health were present in only two patients (18.1%). Only one patient had associated tuberculosis symptoms (9%). None of the patients underwent the Mantoux test, as a positive reaction did not confirm and negative reaction did not exclude the diagnosis. Among the battery of investigations available, the Mantoux test had low sensitivity and specificity in arriving at a diagnosis of tuberculosis.
Lumpectomy was done in seven (63.6%) cases. Mastectomy, done in one case, was certainly an error on the part of the surgeon. The diagnosis of malignancy was entertained clinically as well as preoperatively considering the age (42 years), hard, non-mobile lump, with nipple retraction and axillary lymphadenopathy.
Microscopically there was evidence of tuberculosis with a varying degree of caseation and well-formed granuloma, composed of Langhan's giant cell, epitheloid cells, mononuclear cell infiltration, and surrounding fibrosis [Figure 1].
|Figure 1: Photomicrograph showing well-formed granuloma with Langhan's giant cell (H and E, 40?)|
Click here to view
A similar pathology was seen in the lymph nodes. Acid fast bacilli were observed in four cases (36.3%). In three cases the caseating necrosis was well-advanced and the lesion had transformed into a frank abscess. All the cases were kept on suitable antitubercular chemotherapy and followed up for a mean period of six months, with isoniazid, rifampicin, pyrazinamide, and ethambutol for the first two months, and they were continued on isoniazid and rifampicin for the next four months. Seven patients showed gradual recovery with decrease in erythrocyte sedimentation rate (ESR) and increase in body weight. Extension of antitubercular therapy from 12 to 18 months was required in three patients, on the basis of their slow clinical response. One patient needed the addition of streptomycin and ofloxacin to the treatment protocol, and responded well.
| Discussion|| |
Breast is remarkably resistant to tuberculosis as are skeletal muscles, thyroid, and spleen.  Tuberculosis of the breast is extremely uncommon in the western population, but accounts for 3% of surgically treatable breast conditions in India.  We found that mammary tuberculosis comprised of 4.1% of breast diseases.
As compared to the other authors the incidence of tuberculosis breast is high in our series; this may be because of the overall increase in the incidence of tuberculosis [Table 3].
Tuberculosis of the male breast is an extremely rare condition. Lilleng et al., in a study of 809 cases of male breast mass, did not find a single case.  A few isolated case reports on male breast tuberculosis revealed that the common mode of presentation was a unilateral breast mass with or without ulceration along with axillary lymphadenopathy.  In our series also all patients were females.
Mammary tuberculosis may be primary or secondary to a lesion elsewhere in the body.  According to this classification, all our cases can be labeled as primary, as no other focus of active tuberculosis was observed at any other site. There are four possible routes of infection to the breast namely, (i) Direct infection through ducts at the nipple or through abrasion in the skin, a probable, but not common mode of infection. (ii) Hematogenous spread as a part of miliary tuberculosis, this route is again very rare, although Raven  reported a case of tuberculosis of the breast along with multiple other lesions in the body. A similar case has been reported by Gupta and Rama Rao.  On the other hand Nagshima  has dissected 34 cases of military tuberculosis and has not found involvement of the breast. (iii) The third route of infection is via lymphatics, predominantly retrograde infection from the axillary, mediastinal, cervical, and other lymph nodes. This is a very common route of infection. In four of our cases, the axillary lymph nodes were involved and removed during a mastectomy operation. Histologically all these cases showed tuberculosis. Whether the axillary lymph node was the site of primary infection or secondary to mammary tuberculosis is a debatable point. (iv) The other route of infection is the direct spread by contact from the underlying ribs, pleura, and lungs.
Breast tuberculosis is more frequent during the active sexual period of life (20 - 40 years). It is extremely rare before the tenth year. Morgen  in his review of 439 cases did not find any case between 1 and 10 years. The highest incidence was between 20 and 40 years. In Indian literature most of the cases reported were in this age group; Choudhari 85%,  Dharkar et al. 100%,  Dubey and Agarwal 70%,  Diwan and Shinde 43%,  and Bahadur et al. 61.5%.  In our series 81.8% patients were in this age group. During this period, the mammary glandular activity was at its peak. This should be of considerable help in differential diagnosis, as in any case, with a preoperative diagnosis of mammary carcinoma in this age group, in this country, with a high prevalence, mammary tuberculosis should be kept in mind.
Lactation is known to increase the susceptibility to develop breast tuberculosis. Banerjee et al. found 33% of their patients to be lactating at the time of presentation,  while Khanna et al. reported 30% of their patient lactating.  In our series, 45.4% of the women were lactating at presentation. In these women, perhaps the stress of child bearing and increased vascularity of the breast facilitated infection and dissemination of the bacilli. One interesting hypothesis from a series in India correlates to the prevalence of tuberculosis in the faucial tonsils of sucking infants with a higher incidence of tuberculosis of the breast in lactating women.  There are no reports in the literature on the presence of acid fast bacilli in the milk of such women, even though it was possible to isolate acid fast bacilli in 12% of the breast biopsies. 
Only two cases were suspected as tuberculosis on clinical grounds. In the Pratap et al. series, tuberculosis was clinically diagnosed in two out of 23 cases. Clinically, tuberculosis of the breast should be suspected if there is a lump with chronic discharging sinus or chronic tender lump without any other signs of inflammation. However, there are no definite clinical signs and often it mimics carcinoma breast. It is thus desirable to always wait for a histopathological report before undertaking mastectomy and the patient may be spared much of the physical and metal discomfort. There was one such case in our series.
There are three clinical varieties of mammary tuberculosis, namely, nodular, disseminated, and sclerosing.  The nodular variant is often mistaken for a fibroadenoma or carcinoma. The disseminated variety commonly leads to caseation and sinus formation. Sclerosing tuberculosis afflicts older women and is slow growing, with the absence of suppuration.
Tuberculosis mastitis is diagnosed reliably by histological evidence of epithelioid granulomas, Langhan's giant cells, and lymphohistiocytic aggregates. Mastectomy is never indicated in breast tuberculosis and surgery is limited to the excision of the sinuses and / or lumps, incision, drainage, and curettage of the chronic abscess. The present study reveals that although tuberculosis of the breast is an uncommon condition, it is a definite clinical entity. It may mimic benign or malignant lesions of the breast, and therefore, no major surgery of the breast should be undertaken without prior histopathological examination.
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[Table 1], [Table 2], [Table 3]
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