Tuberculosis of the breast: A case report in a tertiary health institution, South-South Nigeria

INTRODUCTION

Breast tuberculosis (TB) is a rare disease with a reported incidence of <0.1% of all breast lesions in Western countries.^[1] The incidence in TB-endemic regions such as India and Africa is between 3% and 4%. Breast TB has a multifaced presentation, and it is, therefore, labeled as a “great masquerade.”^[2] The clinical presentation of breast TB is often insidious and non-specific, mimicking the signs of breast carcinoma.^[1] The disease affects women of reproductive age between the ages of 21 and 30 years and can present as a breast abscess, a one-sided painless breast mass,^[3] or sinus, and it may sometimes mimic breast cancer.^[4] A high index of suspicion, a search for risk factors, and a histological diagnosis are necessary tools in its diagnosis to avoid mismanagement of potentially curable breast disease.^[5] Histopathological examinations are more important than bacteriological examinations to confirm a diagnosis of breast TB.^[6] Furthermore, fine-needle aspiration cytology (FNAC) proved in the diagnosis of breast TB, thereby preventing unwarranted surgical removal.^[7] The incidence of breast TB in Nigeria is unknown due to the paucity of information.^[8] Hence, breast TB should be a breast lump differential in endemic regions like Nigeria.

We present a case of an 18-year-old female with a left upper quadrant breast lump of 1-year duration. The FNAC of the breast lump was negative for malignancy. In addition, the excision of the breast lump was done, and a histological diagnosis confirmed granulomatous mastitis consistent with breast TB. The post-surgical period was uneventful and she was referred to the endemic disease unit for further management.

CASE REPORT

We report an 18-year-old teenage girl who presented with 12 months history of a lump in her left breast with intermittent pains. She had no history of swelling on the other part of her body and nil history of contraception nor a family history of breast cancer. There was no associated nipple discharge, breathlessness, or drenching night sweats. However, there was associated progressive weight loss. A provisional diagnosis of fibroadenoma to rule out malignancy was made. She underwent a fine-needle aspiration, which was negative for malignancy. Furthermore, an excisional biopsy was done and sent for a histopathology examination.

Histopathologic findings were: Macroscopically, the specimen consisted of multiple irregularly shaped breast masses with an aggregate weight of 50 g. The largest mass measures 4.0 cm × 3.0 cm × 1.5 cm, and the smallest mass was 1.0 cm × 0.9 cm × 0.5 cm. Their external surfaces were smooth and shiny and cut surfaces were friable with a creamy color to yellowish appearance. The microscopic features of breast TB are revealed in [Figure 1a-e]. The histologic sections revealed numerous granulomas consisting of mononuclear inflammatory cells, epithelioid cells, areas of caseous necrosis, and giant cells of Langhans, which were in keeping with tuberculous granuloma.

Close

Figure 1(a-e):

Photomicrograph of breast tissue stained with routine hematoxylin and Eosin showing granulomas consisting of epitheloid-like cells, mononuclear inflammatory cells, and giant cells of the Langhan types and areas of caseous necrosis. The arrows in figure 1a; Langhan giant cells. (b) Periductal Inflammation, (c) giant cells of Langhan type, (d) proliferating breast ducts, (e) granulomas and areas of caseous necrosis.

Export to PPT

She was referred to the endemic disease unit for antituberculous medication and treatment. She recovered fully without complications and was discharged home with contact tracing done. Breast TB should be an important differential diagnosis of fibroadenoma of the breast.

DISCUSSION

Globally, tuberculous mastitis is rare and uncommon even in regions where TB is endemic and essentially poses a diagnostic challenge as it usually masquerades as carcinoma or other primary diseases of the breast.^[3] FNAC is the most commonly used diagnostic method representing 32%, followed closely by biopsy (27%), Ziehl–Neelsen stain for acid-fast bacillus (26%), culture (13%), and polymerase chain reaction (2%).^[7] Primary breast TB arises through openings or abrasions of the nipple ducts. The more common secondary form spreads through lymphatic, hematogenic, or adjoining seeding from the ribs, pleural space, or rectus sheath on an intra-abdominal basis.^[9] Quaglio et al., in their study of 1478 cases of TB breast, showed that 19% of the women had a previous history of breast TB and the most common clinical appearance of the lesion was breast lump (75%) with associated findings of axillary lymphadenitis (33%) followed by sinus or fistula (24%), while the most common symptoms include fever and pain, which reported in 42% and 28% of cases, respectively. A tissue biopsy is essential for confirmatory diagnosis, also to rule out any coexisting malignancy.^[10]

In the index case, the patient presented with a breast mass with intermittent pain and slight weight loss. However, there was no palpable axillary mass. The aspiration cytology report was negative for malignancy but not conclusive of breast TB. An excisional biopsy of the breast lump was done, and the histologic appearance was that of TB of the breast.

CONCLUSION

Breast TB must always be a differential diagnosis of breast abscess, lump, or fistula with poor response to empiric antibiotic treatment, especially in TB-endemic regions like Nigeria. Histopathologic evaluation is necessary for the diagnosis of breast TB. We recommend that private practitioners, family physicians, and general surgeons send all excised breast lump tissue removed from all patients, irrespective of age, for histopathologic studies for appropriate and definitive diagnosis to prevent diagnostic error and unnecessary mastectomy in potentially curable breast disease.