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BILATERAL BREAST TUBERCULOSIS : AN UNUSUAL PRESENTATION
NK Navani*, SS Bhagwat*, AP Chaphekar**, AC Pinto***, SV Shetty****
*Registrar; **Lecturer; ***Hon. Assistant Surgeon and Assistant Professor; ****Hon. Surgeon and Professor of Surgery, Dept. of Surgery, Dr. RN Cooper Municipal General Hospital and Seth GS Medical College, Mumbai.
An unusual case of bilateral breast tuberculosis presenting as breast lumps is discussed.
INTRODUCTION
Tuberculosis of breast is an uncommon disease which is often difficult to differentiate from cancer of breast when presenting as a lump. In India an incidence of 0.63% to 4.5% has been reported.[3] [4] [5] [6] [7] Bilateral breast tuberculosis is extremely rare, accounting for only 3% of patients with breast tuberculosis.[3]
CASE REPORT
A 40 year old married female presented with progressively increasing bilateral, painless breast lumps of one month duration. She gave a history of low grade evening fever with loss of weight and appetite for six months. There was no history of any discharge from either nipple.
She had a non tender, firm, well defined, freely mobile lump in both breasts. The right breast lump was in the upper outer quadrant and measured 4 cm x 4 cm, while the left breast lump occupied the upper inner quadrant and measured 3 cm x 3 cm. There was no evidence of fixity to the skin or the underlying tissues. The nipple, areola and the skin of both breasts were normal. There was no axillary or cervical lymphadenopathy. The chest examination was normal. Examination of the abdomen revealed no evidence of any intra abdominal lump or ascites.
Haemoglobin was 8.6 gm%, WBC count was 7,800 with polymorphs 54%, lymphocytes 42%, eosinophils 04%, ESR was 80 mm at end of one hour by Westergren method. Liver function tests were normal. Chest X-ray showed apical calcification and fibrosis in the right lung. Sputum was negative for mycobacterium tubercle. Fine needle aspiration cytology (FNAC) was done on both the breast lumps and showed tuberculous granulomas consisting of caseation, epitheloid cells and Langhan’s giant cells.
The patient was started on anti tuberculous therapy of streptomycin, INH, rifampicin and pyrazinamide for 2 months and then continued on INH, rifampicin for 6 months during which time she was regularly followed up. There was significant symptomatic improvement with a remarkable decrease in size of both the lumps within one month of anti tuberculous therapy and within five months both the lumps were just palpable.
DISCUSSION
The low incidence of breast tuberculosis may be due to the high resistance offered by the mammary glands to the survival and multiplication of mycobacterium tubercle[6] and also probably because of lack of awareness about manifestations of the disease.[2] A lump is the most common presentation and is often firm to hard, ill defined making it clinically indistinguishable from a carcinoma.[3] The classical presentation with multiple sinuses, ulcers, matted lymph nodes, and a breast lump is less common and occurs late in the course of the disease.[1] [3] Co-existing carcinoma is rare and only six cases have been reported.[7]
Although it was initially believed that most cases of breast tuberculosis were primary, it is now accepted that mammary tuberculosis is almost invariably secondary to involvement of axillary or cervical lymph nodes and less commonly from a pulmonary focus.[4] In our patient it was more likely to be from the pulmonary focus as our patient had no axillary or cervical lesions and had an apical lesion in the right lung. Both haematogenous and lymphatic spread play a major part in the occurrence of this disease.[2]
Demonstration of acid fast bacilli from the lump is usually difficult and the presence of caseation, epitheloid cell granulomas and evidence of tuberculosis of the draining lymph nodes is sufficient for diagnosis.[1] [3]
Fine needle aspiration cytology has proved to be very useful for diagnosis of breast tuberculosis as in this case and reflects the histopathological lesion very accurately. [2] [5]
Treatment with standard anti tuberculous drugs has proved to be very successful and avoids unnecessary mutilating surgery.[7]
CONCLUSION
The aim of this report is to draw attention to the unusual presentation of tuberculosis as a bilateral breast lump without discharging sinuses. Early diagnosis before sinuses develop is important to prevent disfigurement. Hence though rare, breast tuberculosis should be considered as a differential diagnosis in clinically suspicious breast lumps in places with a high incidence of tuberculosis.
REFERENCES
1. Algaratnam TT, Ong GB. Tuberculosis of the breast. Br J Surg 1980; 67 : 125-6.
2. Azzopardi JG. Problems in Breast Pathology. In JL Bennington (Ed) : Major Problems in Pathology. WB Saunders, Philadelphia. 1979; 399-400.
3. Banerjee SN, Ananthakrishnan MS, Prakash S. Tuberculous Mastitis : A continuing Problem. World J Surg 1987; 11 : 105-9.
4. Dharkar RS, Kanhere MH, Vaishy ND, Bisaraya AK. Tuberculosis of the breast. J Indian Med Assoc 1968; 50 : 207-9.
5. Kline TS. Handbook of Fine Needle Aspiration Cytology, CV Mosby Co., St. Louis. 1981; 117-8.
6. Mukerjee P, George M, Maheshwari HB, Rao CP. Tuberculosis of the breast. J Indian Med Assoc 1974; 62 : 410-12.
7. Sarin R, Verma K, Kapur BML, Dass S. Tuberculosis of the breast. Ind J Surg 1984; 46 : 27-31.
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