The International Journal of Mycobacteriology

CASE REPORT
Year
: 2022  |  Volume : 11  |  Issue : 3  |  Page : 323--325

Image-guided fine-needle aspiration cytology or core biopsy – A key to definitive diagnosis of tuberculous mastitis


Shirish Sahebrao Chandanwale, Rajeshwari Ravishankar, Anshita Atul Garg, Mayur Ravindrarao Ambekar 
 Department of Pathology, Dr. D. Y. Patil Medical College, Pune, Maharashtra, India

Correspondence Address:
Shirish Sahebrao Chandanwale
No. 75/1 + 2/1, Krishna Appt, New Sangvi Pune - 411 027, Maharashtra
India

Abstract

Despite advances in the treatment, tuberculosis (TB) is still a global health problem. The diagnosis of extrapulmonary TB in their primary form is very challenging. Breast TB is very uncommon and accounts for < 0.1% of all breast lesions. Due to rarity of the disease and difficulty in diagnosis, we report a case of a 40-year-old female who had a hard lump in the right breast. Full-field digital mammography suggested the lesion as American College of Radiology Breast Imaging Reporting and Data System-5 (ACR BIRADS-5) (highly suggestive of carcinoma). Histopathological examination of multiple cores of the breast tissue showed lymphocytic inflammatory infiltrates confined to breast lobules. Fungal stains and Ziehl–Neelsen (ZN) stain were negative. A diagnosis of chronic mastitis with the possibility of autoimmune lobular mastitis was suggested. Subsequent image-guided fine needle aspiration smears showed epithelioid granulomas mixed with lymphocytes. Areas of amorphous-to-granular eosinophilic material (caseous necrosis) were seen at places. ZN stain showed acid-fast bacilli. A diagnosis of tuberculous mastitis was given.



How to cite this article:
Chandanwale SS, Ravishankar R, Garg AA, Ambekar MR. Image-guided fine-needle aspiration cytology or core biopsy – A key to definitive diagnosis of tuberculous mastitis.Int J Mycobacteriol 2022;11:323-325


How to cite this URL:
Chandanwale SS, Ravishankar R, Garg AA, Ambekar MR. Image-guided fine-needle aspiration cytology or core biopsy – A key to definitive diagnosis of tuberculous mastitis. Int J Mycobacteriol [serial online] 2022 [cited 2022 Dec 5 ];11:323-325
Available from: https://www.ijmyco.org/text.asp?2022/11/3/323/355934


Full Text



 Introduction



Despite advances in the treatment, tuberculosis (TB) is still a global health problem. The diagnosis of extrapulmonary TB in their primary form is challenging. Breast TB is very uncommon and accounts for <0.1% of all breast lesions.[1],[2] The incidence of TB is increasing due to rise of underlying immunosuppressive diseases such as AIDS and emergence of drug-resistant strains of Mycobacterium tuberculosis.[3]

Breast TB is difficult to diagnose, and sometimes, it is misdiagnosed as breast carcinoma. Breast TB is also needed to be distinguished from other forms of chronic mastitis for therapeutic purpose. Due to rarity of the disease and difficulty in diagnosis, we report a case of a 40-year-old female who had a hard lump in the right breast.

 Case Report



A 40-year-old female patient came to the surgical outpatient unit with the complaint of a hard painless lump in the right breast for 1 month. She gave a history of on-and-off fever for the past 2 months. She had no other history of illness in the past. She has two children and the youngest was 10 years old.

Physical examination revealed a hard lump (6 cm × 4 cm) in the lower quadrant of the right breast. Nipple was retracted [Figure 1]a. Axillary lymph nodes were not palpable. Routine hematological parameters were within normal limits, except erythrocyte sedimentation rate being slightly raised. She was HIV seronegative. Chest X-ray showed no abnormality.{Figure 1}

Ultrasonography (USG) showed an ill-defined collection with internal echo measuring 3.4 × 1.9 × 2.0 and 3.3 × 1.1 × 1 cm in the inferior quadrant of the right breast. No significant lymphadenopathy was noted. Residual collections in the right breast with ramifications were suggested.

Full-field digital mammography showed overlying skin thickening at the nipple–areolar region. The two well-defined oval hypodense lesions were noted in the central mammary region of the right breast. Three-dimensional breast tomosynthesis showed multiple oval-to-irregular hypodense lobulated lesions in all quadrants of the right breast with the largest in outer quadrant measuring 4.8 cm × 3.5 cm. There were diffuse thickening of skin and edema of the subcutaneous planes of right breast. A diagnosis of ACR BIRADS-5 (highly suggestive of carcinoma) was suggested.

Multiple breast tissue cores were received for histopathological examination. Histopathological examination showed lymphocytic inflammatory infiltrate confined to breast lobules [Figure 1]b. There were no epithelioid granulomas or caseous necrosis or fungal hyphae. Ziehl–Neelsen (ZN) stain did not show acid-fast bacilli (AFB). A diagnosis of chronic mastitis with the possibility of autoimmune lobular mastitis as suggested.

In view of hard palpable lesion, surgeons sent USG-guided fine needle aspiration (FNA) smears. Prior written consent was taken from the patient. Microscopic examination of the smears showed many cohesive flat sheets of the ductal epithelial cells with round regular nuclei and epithelioid granulomas mixed with lymphocytes [Figure 1]c and [Figure 1]d. Areas of amorphous-to-granular eosinophilic materials (caseous necrosis) were seen at places. Occasional histiocytic giant cell was seen. Few AFB were seen on ZN stain. A diagnosis of breast TB was suggested. Subsequent culture examination for AFB also confirmed the diagnosis of TB.

 Discussion



The breast tissue provides resistance to survival and multiplication of tuberculous bacilli. Breast TB is even rare in the regions where TB is endemic. It is more common in reproductive age due to hypervascularity of the breast tissue and dilated lactiferous duct.[4] The incidence of TB is increasing worldwide due to emergence of drug-resistant strain and HIV infection.

Primary TB of the breast can occur due to direct inoculation of TB bacilli through lactiferous ducts. However, it is more frequently secondary to a tuberculous focus in the lungs, pleura, or lymph node, which may not be detected clinically or even with imaging techniques. Similar observation was made in our case.

Although breast TB affects young and lactating women, some recent case series observed in the mean age group of 32 and 42 years.[4],[5] It is often misdiagnosed because of highly variable clinical, imaging features and lack of familiarity of many clinicians with this entity.

Based on clinical and ultrasound findings, breast TB is classified into three types.[6] (1) Nodular type consists of slowly growing single or multiple masses with or without sinus tract or skin ulcer. (2) Disseminated type consists of diffuse coalescent multiple foci of hypoechoic tissue with sinus tract or skin ulcer. (3) Tubercular breast abscess consists of liquefied breast lesions which may have sinus tract or skin ulcer.

Mammography has limited value in diagnosis, and the findings include diffusely increased density, focal asymmetry, and solid or multiple masses. USG is a valuable and essential complementary modality to mammography, not only for evaluating the extent of the disease but also for performing an image-guided biopsy and percutaneous abscess drainage. Computed tomography and magnetic resonance imaging are complementary modalities that reveal the extramammory extent of the disease. With clinical and radiological findings alone, breast TB is often difficult to distinguish it from carcinoma and other forms of mastitis.

Definitive diagnosis of breast TB in FNA smears is based on epithelioid granuloma, necrosis, and AFB in ZN staining. However, the prevalence of AFB in breast FNA smears is very low and ranges from 0% to 38.6%.[6],[7] A core needle biopsy provides better sample and is necessary to diagnose breast TB.[3] The definitive diagnosis on core biopsy could not be made in our case. The reason can be nonrepresentative sampling. In our case, definitive diagnosis was made on FNA smears because the sample was representative.

The patient was started antitubercular chemotherapy of rifampicin, isoniazid, ethambutol, and pyrazinamide once a day and clarithromycin twice a day. The patient showed improvement after 1 month clinically and radiologically and is on close follow-up.

 Conclusion



Breast TB is still uncommon form of extrapulmonary TB. Clinical and imaging findings are variable. It is needed to be distinguished from carcinoma and other forms of mastitis for proper treatment. Representative sample from the lesion in FNA and core biopsy can provide a definitive diagnosis. Image-guided FNA cytology or core biopsy should be recommended in suspected cases of tuberculous mastitis. Culture for AFB is the gold standard for confirmation.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Limitation of study

No long-term follow-up of the patient is available.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Ramaema DP, Buccimazza I, Hift RJ. Prevalence of breast tuberculosis: Retrospective analysis of 65 patients attending a tertiary hospital in Durban, South Africa. S Afr Med J 2015;105:866-69.
2Longman CF, Campion T, Butler B, Suaris TD, Khanam A, Kunst H, et al. Imaging features and diagnosis of tuberculosis of the breast. Clin Radiol 2017;72:217-22.
3Thimmappa D, Mallikarjuna MN, Vijayakumar A. Breast Tuberculosis. Indian J Surg 2015;77:1378-84.
4Farrokh D, Alamdaran A, Feyzi Laeen A, Fallah Rastegar Y, Abbasi B. Tuberculous mastitis: A review of 32 cases. Int J Infect Dis 2019;87:135-42.
5Ghalleb M, Seghaier S, Adouni O, Bouaziz H, Bouida A, Hassouna JB, et al. Breast tuberculosis: A case series. J Med Case Rep 2021;15:73.
6Tewari M, Shukla HS. Breast tuberculosis: Diagnosis, clinical features & management. Indian J Med Res 2005;122:103-10.
7Bani-Hani KE, Yaghan RJ, Matalka II, Mazahreh TS. Tuberculous mastitis: A disease not to be forgotten. Int J Tuberc Lung Dis 2005;9:920-5.