Breast tuberculosis- clinical spectrum and management

Features of breast tuberculosis determined by ultrasound imaging: report of 45 cases

Objective

This study aimed to characterize the ultrasound (US) imaging features of breast tuberculosis (BTB) to clarify the process of disease progression and provide valuable clinical information.

Methods

We retrospectively reviewed 45 patients with pathologically or GeneXpert-confirmed BTB from January 2010 to December 2017. We assessed the US features of target lesions including size, shape, orientation, margin, echogenicity, calcification, posterior acoustic features, and blood-flow signal.

Results

The patients were classified with nodular (55.5%, 25/45), abscess (15.6%, 7/45), or sinus (28.9%, 13/45) type according to their US features. Forty lesions (88.9%, 40/45) extended in a parallel orientation and five extended in a non-parallel orientation. Calcifications were found in eight cases, including six macrocalcifications and two microcalcifications. Enlarged axillary lymph nodes were observed in three cases (6.7%, 3/45). In addition, 44 of the 45 cases (97.8%, 44/45) exhibited hypovascularity or avascularity according to color Doppler flow imaging (CDFI).

Conclusion

BTB lesions can be classified as nodular, abscess, or sinus type according to their US imaging features. Poor blood supply detected by CDFI might be a common US feature of BTB. Characterization of its US features may facilitate the clinical diagnosis of BTB.

Internal thoracic lymphadenopathy and pulmonary tuberculosis

OBJECTIVE

Internal thoracic lymphadenopathy (ITL) has been associated with malignancies and non-tuberculous empyema. However, the association between ITL and active pulmonary tuberculosis (PTB) and the correlation between ITL and other imaging characteristics of active PTB has not been examined.

MATERIALS AND METHODS

A retrospective cohort study comprising 137 adults with active PTB who had a concomitant chest CT over a seven-year period was conducted. Two thoracic radiologists evaluated for ITL as well as nine other imaging characteristics of active tuberculosis, including total lung involvement (as measured by a total severity score), number of nodules, presence of tree-in-bud nodularity, highest extent of tree-in-bud nodularity in a lobe, miliary pattern, cavitary lesions, pleural effusion, lymphadenopathy (excluding internal thoracic lymph nodes), and empyema. The Wilcoxon rank-sum test and chi-squared tests were used to assess the correlation between ITL and additional imaging findings.

RESULTS

Internal thoracic lymphadenopathy was present in 50 of 137 cases (36.5%); most commonly bilateral (19.0%) or isolated on the right side (13.7%), and less commonly isolated on the left side (3.7%). Pleural effusion, lymphadenopathy (apart from internal thoracic compartment), and empyema all showed statistically significant correlations with ITL (p-values of <0.0001).

CONCLUSIONS

While the presence of ITL - particularly when accompanied by other imaging findings such as pleural effusion - may prompt a radiologist to first consider malignancy, active PTB should be an additional consideration in the appropriate clinical context.

Imaging and clinical features of breast tuberculosis: a review series of 62 cases

AIM

To outline the disease burden of breast tuberculosis (TB) as a quantitative analysis amongst three tertiary hospitals in South Africa, with correlation to their clinical, demographic, and imaging features.

MATERIALS AND METHODS

A retrospective analysis was undertaken over an 18-month period (01/01/2017-30/06/2018) of all patients undergoing laboratory investigations for breast disease at the mammography departments of these three tertiary centres.

RESULTS

The prevalence of breast TB was 2.5% (n=62) of 2,516 patients. The median age of presentation was 38.5 years (interquartile range [IQR] 33-45). HIV status was known in 45 patients, of whom 36 were HIV infected (80%, 95% CI: 0.65-0.90, p<0.0001). Based on the ultrasound and/or mammogram findings, the patients were classified into five categories: TB breast abscess (40.3%), inflammatory/disseminated (24.2%), isolated TB lymphadenitis (22.6%), nodular (11.3%), and sclerosing form (1.6%). Histology demonstrated necrotising granulomatous inflammation in 57 cases (92%). Acid-fast bacilli (AFB) were positive in 8.1% (n=5) of the cytology and 16.1% (n=10) of the histology specimens. Culture for Mycobacterium tuberculosis was positive in 27% (17 cases), and in 12.9% (n=8). AFB were detected histologically using polymerase chain reaction (PCR) testing.

CONCLUSION

Knowledge of the varied clinical and radiological features is necessary to maintain a high degree of suspicion to prevent misdiagnoses, inappropriate management, and complications. Ultrasound-guided core biopsy rather than fine-needle aspiration (FNA) is advocated as the first-line intervention in diagnosing or excluding this disease, as it yields a better tissue sample and more often a positive diagnosis.

Breast Tuberculosis in Women: A Systematic Review

Breast tuberculosis (TB) is rarely reported and poorly described. This review aims to update the existing literature on risk factors, clinical presentations, constitutional symptoms, diagnostic procedures, and medical and surgical treatments for breast TB. In all, 1,478 cases of breast TB were collected. Previous history of TB was reported in 19% of cases. The most common clinical appearance of the lesion was breast lump (75%). The most common associated finding was axillary lymphadenitis (33%) followed by sinus or fistula (24%). The most common symptoms were pain and fever, reported in 42% and 28% of cases, respectively. The most used diagnostic method was fine-needle aspiration cytology (32%), followed by biopsy (27%), acid-fast bacteria Ziehl-Neelsen stain (26%), culture (13%), and polymerase chain reaction (2%). These tested positive in 64%, 93%, 27%, 26%, and 58% of cases, respectively. The majority (69%) of patients received a 6-month anti-TB treatment (isoniazid, rifampicin, pyrazinamide, and ethambutol). Surgery consisted of excision in 39% of cases, drainage in 23%, and mastectomy in 5%. The great majority of patients had a positive outcome. It often mimics breast cancer, which makes it difficult to diagnose. Most patients, when diagnosed in time, respond to antitubercular therapy alone.

Breast tuberculosis in East London: A 13-year retrospective observational study

SETTING

Breast tuberculosis (TB) is rare in Western Europe, and its diagnosis may be delayed through lack of awareness of presenting features. Our institution serves a large East London population with a high incidence of TB.

OBJECTIVE

To characterize presenting features and avoidable diagnostic delay in breast TB patients.

DESIGN

We conducted a 13-year retrospective study of breast TB patients treated at our institution including demographic, clinical, microbiology, and pathology data.

RESULTS

Forty-seven cases were included; 44 (94%) were female, with a median age of 33 years (IQR 28.5-39.5). The main presenting feature was a breast lump in 41 cases (87%); which were predominantly solitary unilateral lesions (25, 61%) and frequently located in the upper outer quadrant (28, 68%). Where performed, Mycobacterium tuberculosis was cultured in 15/36 (42%) cases. Granulomata were present on biopsy or aspirate in 21 (47%) and 17 (36%) cases, respectively. The median duration between symptom onset and treatment was 20 weeks (IQR 15-30). Forty-six (98%) completed treatment successfully and one relapsed.

CONCLUSION

A high index of suspicion for TB is required for individuals presenting with breast symptoms from countries where TB is endemic. Development of standardized pathways may improve detection and management of breast TB may reduce diagnostic delay.

Fine needle aspiration cytology in Mozambique: Report of a 15-year experience

BACKGROUND

Fine needle aspiration cytology (FNAC) is an important diagnostic tool in a range of medical settings. It is fast, quick and a highly accurate diagnostic method and can be used, in settings with minimal laboratory infrastructures.

METHODS

In this report, we describe the experience in the use of FNAC since it is introduction in 1996 in the Anatomical Pathology Service of the Maputo Central Hospital (MCH), along with more detailed data referring to 2009-2010.

RESULTS

The number of FNAC analyses increased gradually from 269 (4.1% of all pathologic tests of the Service) in 1996, when it was introduced in Mozambique, to 3234 (17% of all tests) in 2010. Lymph nodes were the organs most frequently biopsied, followed by breast and soft tissues. Inflammatory conditions, especially tuberculosis, were the most frequent diagnoses (22.2% of the cases), followed by hyperplastic conditions (20.6%), benign tumors (13.4%) and malignant tumors (12.3%).

CONCLUSION

Our results clearly demonstrate that even in an environment with poor laboratory resources, it is possible to establish a FNAC clinic that can provide a quick and precise diagnosis for clinicians to aid in early treatment interventions, especially in inflammatory diseases which were the majority of our cases.

Breast tuberculosis in men: A systematic review

Setting

Breast tuberculosis in male is a rarely reported and poorly described condition.

Objective

To quantify the number of breast tuberculosis in men, to describe clinical presentation and to present the diagnostic and therapeutic procedures applied.

Design

A systematic review of the literature including reports published in English, Spanish and French until December 2017.

Results

The search yielded 26 cases of male breast tuberculosis, median age 56.5 years. Most presented with an isolated breast lump (89%), associated with axillary lymphadenitis (27.8%) and skin inflammation (33.3%). The most common constitutional symptoms were pain (64.7%) and fever (35.3%). Fine-needle aspiration cytology and culture were the most common diagnostic modality (61.5%). Standard anti-tuberculosis regimen was the main treatment, alone or accompanied or preceded by incision and drainage.

Conclusions

The risk of breast tuberculosis in men appears to be low, but the condition can be difficult to diagnose and the diagnostic delays can be long. Overall prognosis is good following standard anti-tuberculosis regimen with or without incision/drainage.

Tuberculosis of the Breast in Togo: A Series of 28 Presumed Cases

Our study aimed to describe the epidemiological, clinical and histological aspects of mammary tuberculosis in Togo. This is a descriptive cross-sectional study of breast tuberculosis for which the diagnosis was presumed on histological grounds in the pathology department (LAP) of the Lomé Tokoin university hospital from January 1995 to December 2016 (20 years). A total of 28 presumed cases of mammary tuberculosis were identified. There were 26 women and 2 men, with an average age of 34.2 ± 0.3 years. The clinical signs were nodule (84.1%), tumefaction (75%), abscess (63.6%) and tumefaction with cutaneous fistulization (59.1%). Breast involvement was isolated in 31.8% of cases and associated with pleuropulmonary tuberculosis in 54.5% of cases. Co-infection with HIV was found in 63.9 % of cases. Histology showed inflammatory granulomas made of Langhans giant cells, epithelioid cells and lymphocytes around the foci of caseous necrosis. Thoracic radiography was abnormal in 16 patients (57.1%).Mammary tuberculosis is not rare in our country. Clinical presentation is often misleading and is a diagnostic challenge, more particularly with breast abscess or cancer.

Clinical and Cytological Spectrum of Granulomatous Mastitis and Utility of FNAC in Picking up Tubercular Mastitis: An Eight-Year Study

INTRODUCTION

Granulomatous Mastitis (GM) is a rare, benign, inflammatory disease of the breast. It is a well known mimicker of malignancy, clinically and radiologically. Patients are often subjected to number of tests for the right diagnosis. Non-specific Granulomatous Mastitis (NGM) and Tubercular Mastitis (TBM) are chief among the various causes of GM. They are important to be diagnosed early as their treatment varies significantly. Fine Needle Aspiration Cytology (FNAC) is simple, patient friendly and primary investigation modality in cases of lump in breast.

AIM

To find out the utility of FNAC in differentiating NGM and TBM.

MATERIALS AND METHODS

All cases of granulomatous mastitis diagnosed on cytology over eight years were retrospectively retrieved. The clinical and radiological history was obtained from the patient file. The slides were stained with haematoxylin and eosin stain as well as Leishman stains. Special stains like Periodic Acid Schiff (PAS) and Ziehl Neelsen (ZN) stain were used for fungus and Mycobacteriumtuberculosis respectively. Histopathological correlation of the available cases was done. Clinical presentation and cytological morphology of individual cases was studied in detail.

RESULTS

Twenty one cases of GM obtained, of which 16 were NGM and five were TBM. Both diseases were common among young reproductive women who presented with unilateral breast lump of varying duration. Almost 25% of NGM and 60% of TBM has clinical suspicion of malignancy. About 30% had radiological suspicion of malignancy. Nearly 62.5% of NGM patients had painful swelling and none of tubercular mastitis patients had pain. About 31% of NGM patients underwent prior abscess drainage and 40% of TBM patients gave history of tuberculosis. Almost 6.25% of NGM and 60% of TBM had axillary lymphadenopathy. Cytologically epithelioid cells were identified in 100% of patients whereas, granulomas were seen in 62.5% and 80% of NGM and TBM smears respectively. Langhans giant cells were frequent among TBM and foreign body giant cell among NGM. Caseous necrosis was seen in 60% of TBM and absent in NGM smears.

CONCLUSION

Though, NGM and TBM is said to have overlapping features, our study highlights few clinical and cytological differences which aid in differentiating the two entities at primary level. FNAC along with special stain must be advocated as the primary tool of diagnosis in cases of GM.

The T-SPOT.TB Test for Diagnosis of Breast Tuberculosis

OBJECTIVE

To assess the diagnostic value of the T-SPOT.TB test in cases of breast turberculosis (BTB) in China.

METHODS

We enrolled 13 female patients with primary BTB as the BTB test group and 10 healthy volunteers as the control group. The 2 groups underwent T-SPOT.TB tests and tuberculin skin tests (TSTs) before receiving a core-needle biopsy or excision biopsy. We then collected and analyzed T-SPOT.TB and TST data.

RESULTS

The sensitivity of the T-SPOT.TB test for detection of BTB (84.6%) was significantly greater than that of TST (53.8%) (P <.05); the specificity of each test (80.0% and 60.0%, respectively) for BTB was not significantly different (P >.05).

CONCLUSION

The T-SPOT.TB test could be a useful adjunct to current tests for diagnosis of BTB and could be used for early diagnosis of this condition.

Breast Tuberculosis after Chest Trauma - a Case Report and Review of the Literature

BACKGROUND

Breast involvement of tuberculosis (TB) is well known but uncommon. It can resemble other diseases, including breast cancer, and diagnosis is quite difficult. So, when facing a breast lesion, a possible tubercular etiology should always be born in mind, relying on qualified laboratories to confirm the diagnosis.

CASE REPORT

We describe a 42-year-old woman with a mammary fistula complicating a post-traumatic lump. A critical analysis of the diagnostic process was performed together with a review of the literature, also considering the potential role of trauma in inducing such a rare complication.

Tuberculous cold abscess of breast: an unusual presentation in a male patient

Tuberculosis (TB) of breast is a rare condition especially presentation as a cold abscess. We present a case of male patient with TB of lung and meninges with a cold abscess in the breast. The abscess was incidental finding on the computed tomography (CT) scan. This was further managed by a combination of anti-tuberculous chemotherapy treatment and surgical drainage. We reviewed the current literature related to mammary TB, its presentations and treatment.

Tuberculosis of the Breast: An Initial Presentation of the Metabolic Syndrome with Type 2 Diabetes Mellitus in a Young Nigerian Woman

Breast tuberculosis is an uncommon presentation of extra pulmonary tuberculosis. A 40-year-old obese woman presented with a right breast abscess which had failed to heal after surgical drainage. There was no family history of breast disease. Biopsy and histology of the lesion showed chronic granulomatous inflammation with positive stains for acid fast bacilli compatible with tuberculosis. Further evaluation confirmed metabolic syndrome with type 2 diabetes mellitus. She was placed on antituberculosis chemotherapy and appropriate therapy for diabetes mellitus with complete resolution of the lesion. We report this case because of its rarity and to highlight the association between tuberculosis an infectious disease and overnutrition in diabetes mellitus, a noncommunicable disease.

Clinical, diagnostic and therapeutic management of patients with breast tuberculosis: Analysis of 46 Cases

Breast tuberculosis is a rare form of extrapulmonary tubercular infection. Our aim is to highlight the nonspecific clinical presentations, diagnostic difficulties and therapeutic approaches of mammarian tuberculosis. Forty-six patients diagnosed with breast tuberculosis between 2005 and 2015 were reviewed retrospectively. Clinical features, all diagnostic methods, and the outcomes of treatment were analysed. All cases were female with a mean age of 36.4 years. Breast mass and pain were the most common complaints. While 34.8% of the cases had a physical examination with suspicions for malignancy, 43.5% of the patients had Breast Imaging Reporting and Data System (BI-RADS) 4 or 5 lesions suggested malignancy radiologically. Definitive diagnosis was based on histopathologic examination through core needle biopsy (n = 29), excisional biopsy (n = 12), and open biopsy (n = 5) taken from the abscess wall during drainage. Standard antiTB therapy for 6 months was given to all cases. Thirty-three patients recovered with standard 6-month therapy while extended treatment for 9-12 months was needed in 13 (28.2%) cases. Surgery was carried out in 17 cases. Two patients developed recurrence. Breast tuberculosis can be easily confused with breast cancer, suppurative abscess, and other causes of granulomatous mastitis, both clinically and radiologically. A multidisciplinary approach is required to prevent diagnostic delays and unnecessary surgical interventions. Although antiTB therapy is the mainstay treatment of breast TB, surgery is usually indicated in patients refractory to medical treatment.

Treatment for and clinical characteristics of granulomatous mastitis

OBJECTIVE

To describe the clinical and paraclinical characteristics of idiopathic granulomatous mastitis, the management of our patients, and review the literature on this topic.

METHODS

Patients referred to our clinic with a presumptive diagnosis of infectious mastitis were only included in the study if they had histopathologic confirmation of granulomatous mastitis. A systemic or infectious etiology was excluded by the testing of tissues and fluids by staining, culture, and polymerase chain reaction methods. Those patients with no reported etiology were categorized as idiopathic granulomatous mastitis and treated with antiinflammatory drugs. All were monitored for signs of recurrence.

RESULTS

All 22 patients with a final diagnosis of idiopathic granulomatous mastitis were women with a mean age (± standard deviation) of 32.8 ± 6.2 years. Initial treatment with a prednisone regimen was given in 15 (68.2%) patients, prednisone plus methotrexate (MTX) in six (27.3%), and MTX alone in one (4.5%). Among the total of 22 patients with idiopathic granulomatous mastitis, 12 (54.5%) received MTX either as an initial treatment or as an alternative regimen. Of the 22 patients, three (13.6%) had disease recurrence and four (18.2%) experienced adverse drug reactions. Sixteen (72.7%) patients discontinued the initial treatment regimen with acceptable control of disease activity and without recurrence or adverse drug reactions during the follow-up period.

CONCLUSION

Idiopathic granulomatous mastitis is a distinct benign breast condition of unknown etiology but several triggers are suspected, including inflammatory, infectious, and hormonal factors. Corticosteroids and MTX, with or without surgery, are the treatment of choice in these patients.

Breast tuberculosis in northeast Iran: review of 22 cases

Background

Breast tuberculosis (breast TB) is an extremely rare disease, so case reviews are also rare.

Methods

This study is a retrospective review of patients with breast TB who were treated between 2002 and 2012 at the Health Center of Gorgan City.

Results

All 22 patients were females, their mean age was 32.4 years, and all were new cases. Patients presented with swelling of the breast (22%), lump (55%) and excretion from the involved breast (27%), and breast pain (55%). The highest rate of breast TB occurred in 2011 (27%). All patients received the DOTS regimen for a mean duration of 7.3 ± 0.7 months; in addition, segmental resection was performed on 11 patients (50%).

Conclusions

The findings confirmed that breast TB in Iran should be considered as a differential diagnosis of breast masses. All patients in our study received the daily and ‘Directly Observed Treatment Short-course’ (DOTS) regimens. Anti-tubercular therapy for six months with or without minimal surgical intervention currently is the main treatment.

Breast tuberculosis in immunocompetent patients at tertiary care center: A case series

The breast tuberculosis (TB) is an extremely rare manifestation for the reason that mammary cells offer great resistance to the survival and multiplication of Mycobacterium infection. The diagnosis is difficult because of nonspecific clinical and radiological findings. It is usually suspected in a multiparous, reproductive woman. We report three cases of tubercular infection of breast confirmed by either mycobacteriology, pathology or both. We described their diagnostic confirmation and six month follow-up after antitubercular treatment (ATT).