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Diagnosing Tuberculosis of Breast: A “Pendular” Experience |
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Rubik Ray, Debajyoti Mohanty, Manish Sahu, Sujata Sarangi, Nighat Hussain 1. Assistant Professor, Department of General Surgery, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India. 2. Additional Professor, Department of General Surgery, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India. 3. Senior Resident, Department of General Surgery, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India. 4. Senior Resident, Department of Pathology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India. 5. Additional Professor, Department of Pathology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India. |
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Correspondence Address : Rubik Ray, Assistant Professor, Department of General Surgery, All India Institute of Medical Sciences, Raipur-492099, Chhattisgarh, India. E-mail: rubikray@gmail.com |
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| Keywords : Diagnostic dilemma, Mammary tuberculosis, Mammography | |||||||||||||||||
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DOI and Others :
10.7860/IJARS/2021/48417:2682
Date of Submission: Jan 06, 2021 Date of Peer Review: Mar 30, 2021 Date of Acceptance: May 06, 2021 Date of Publishing: Jul 01, 2021 AUTHOR DECLARATION: • Financial or Other Competing Interests: None • Was informed consent obtained from the subjects involved in the study? Yes • For any images presented appropriate consent has been obtained from the subjects. Yes PLAGIARISM CHECKING METHODS: • Plagiarism X-checker: Jan 07, 2021 • Manual Googling: May |
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| INTRODUCTION |
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The authors want to apprise the readers of an interesting case of tuberculosis of the breast where clinical features, radiology and even fine needle aspiration cytology indicated that it might be a malignancy thereby causing diagnostic dilemma. A 32-year-old multiparous non-lactating female patient presented with a lump in the left breast since six months duration with gradual increase in size. There were no risk factors for carcinoma. On examination there was a 5.5×3 cm mass in the axillary tail region of the left breast. The lump was non tender, firm in consistency, relatively mobile with regular margins. Multiple mobile axillary lymph nodes were palpable on the affected side. The nipple on the affected side was retracted. Sonography of the breast showed multiple microcalcifications within the mass with increased vascularity. It also showed multiple enlarged axillary nodes with loss of hilum and increased vascularity. The mammography of the breast showed Breast Imaging-Reporting And Data System (BI-RADS) - IVb grading indicating suspicion for malignancy (Table/Fig 1). Fine Needle Aspiration Cytology (FNAC) found focal atypia, classifying it provisionally as a dysplastic lesion. Therefore, supported by the “trifecta” of diagnosis of breast lumps namely clinical, radiology and pathology, the pendulum of the diagnostic clock swung in the direction of a malignancy. However, the pendulum swung in the opposite side when subsequently a tru-cut biopsy of the lump was performed and showed granulomatous inflammation but did not find any evidence of caseous necrosis or acid fast bacilli on Ziehl-Neelsen (ZN) staining. A decision to perform a wide local excision of the lump was taken for proper histologic confirmation after properly counselling the patient on the possible future requirement of a formal mastectomy and axillary clearance, should malignancy be identified. At the time of surgical excision a 4×5 cm lobulated, well-encapsulated mass was found (Table/Fig 2). There was desmoplastic change in the axilla and multiple enlarged lymph nodes in anterior, posterior, lateral and central groups were present. A single lymph node was also sampled during the operation. Facility for cryo-sectioning was not available. Subsequently, histopathology showed that both the lump as well as the lymph node containing multiple granulomas and areas of caseous necrosis compatible with tuberculosis (Table/Fig 3). The patient was started on antitubercular drugs and has responded well to treatment. Tuberculosis of the breast is very rare and generally occurs in reproductive age group (1) with an incidence of 3-4% in highly endemic areas. Over the years few small and moderate size series of breast tuberculosis has been reported in Indian literature (Table/Fig 4) [2-9]. As sporadic cases of tuberculosis breast continue to be reported occasionally, therefore it should always be considered as a differential diagnosis of breast lump in Indian patients. Tubercular mastitis can present as a solitary unilateral lump with ill-defined margins in the upper outer quadrant and can resemble breast malignancy. It might even be fixed to skin or chest wall. Other presentations like ulcer and discharging sinuses are less common [10,11]. Present patient neither had risk factors of breast carcinoma like family history, nulliparity, higher age or oral contraceptive use nor had history of pulmonary or extra-pulmonary tuberculosis. All components of the “triple assessment” like clinical characteristics of the lump, nipple retraction and presence of multiple axillary nodes on the affected side, BIRADS IVb grade on mammography, micro-calcifications along with axillary lymphadenopathy on Ultrasonography (USG) and finding of atypia on FNAC supported a malignant aetiology. However, the finding of granulomatous inflammation on core biopsy raised doubts about the diagnosis. In tuberculous disease of the breast, findings of needle biopsy and imaging are often conflicting and confounding and cause diagnostic dilemma [12,13]. Clinicians must exercise a high index of suspicion, particularly in endemic areas. Excision biopsy remains the only confirmatory option. Four-drug regimen consisting of isoniazid, rifampin, pyrazinamide, and either ethambutol or streptomycin is treatment of choice (1). | |||||||||||||||||
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