Case Report

A 31 year- old- woman admitted with a painful lump in her left breast which has been present since two months. She was treated with non-spesific antibiotic therapy without any improvement. Physical examination revealed a red and tender lump sized 6x5 cm in lower quadrant of the left breast, there were no palpable axillary or other lymph nodes. The rest of the examination was not revealing. First fine needle aspiration biopsy made to the lesion and benign cytology with multiple multinucleated histiocytes seen, then trucut biopsy applied: stromal fibrosis, epitheloid histiocytes, granulomatous mastitis with caseification necrosis reported. PPD was 7x7 mm and CXR was normal.

What is the diagnosis?

1. Breast abcess

2. Carcinoma of the breast

3. Mammary tuberculosis

4. Fungal infection of the breast

Correct answer is: 3) Mammary tuberculosis

Discussion

Tuberculosis of the breast is a rare malady that is usually manifested by a unilateral mass suggestive of carcinoma or sometimes of abcess, with an incidence range between 0.1-3%, for all the breast diseases treated surgically This is a disease of younger women between 20 and 40 years of age.. There are recognized modes of spread of the tubercle bacillus to the breast: hematogenous, lymhatic spread and direct extension. It could produce abcesses, sclerosing lesions resembling carcinoma and multiple nodules. The diagnosis is difficult and to differantiate it from breast cancer is very important.. The most reliable diagnosed studies include bacteriologic studies of aspirate, histologic examination of tissue revealed caseous material.

Tuberculosis is still an important health problem in Turkey. The number of new tuberculosis cases was calculated as 18 418 in 1999 (27 cases per 100 000) (₁).

Sir Astley Cooper reported the first case of tuberculosis of the breast in 1829 and named it “scrofulous swelling of the bosom” (₂,₃) and since then more than 800 cases have been reported (₄). It is a rare disease in Western countries of less than 0.1 % of all breast lesions examined histologically (₂) and 3% to 4.5% of all breast diseases treated sugically in the developing world where tuberculosis is endemic (₅). Tuberculosis involvement of the breast is classified as primary when there is no other identifable site, or secondary when other organs are involved. There are three recognized modes of the tubercle bacillus to the breast. Hematogenous spread involves invasion of the breast by blood-borne tubercle bacilli. Thus it accounts for primary tuberculosis of the breast. Lymphatic spread occurs when intrathoracic or intraabdominal foci of tuberculosis, which spread by antegrade or retrograde extension through the lymphatic vessels. The resultant breast lesion exemplifies secondary tuberculosis mastitis. Also direct extension occurs when an infected rib, costochondral cartilage, or a sternal or shoulder joint spreads infection to adjacent breast tissue. In all cases, tuberculosis infects the ducts and spares the nodules (₆,₇).

Although rare, tuberculosis of the breast should be considered as a possible diagnosis, particularly in countries where tuberculosis is endemic and it could show a resurgence with the global pandemic of AIDS.

Correspondence to

Nese Dursunoglu, Pamukkale University Medical Faculty Department of Pulmonology and Tuberculosis Kinikli 20200 Denizli Turkey Phone: +90 2582118585 Fax: +902582134922 Email: ndursunoglu@yahoo.com