Tuberculosis of breast (study of 7 cases).

PK Sharma, AL Babel, SS Yadav 
 Mobile Surgical Unit, City Hospital, Jaipur, Rajasthan.

Correspondence Address:
P K Sharma
Mobile Surgical Unit, City Hospital, Jaipur, Rajasthan.

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::   Introduction

Tuberculosis of breast is an extrcmely rare disease, only 500 cases of mammary tuberculosis have been documented, most of which are from past generations[5]. Tuberculosis has been named, the great masquerader in recognition of its multifaceted presentation, and thus, the clinician may confuse tuberculous mastitis with either carcinoma or breast abscess. In 1829, Sir Astley Cooper described tuberculosis mastitis as "scrofulous swelling in the bosom of young women"[2]. Since then there have been numerous reports of the disease, the most recent coming from South Africa[4] and India[3] where tuberculosis is still prevalent.

::   Material and method

This study was conducted in RNT Medical College, Udaipur; SMS Medical College and Hospital, Jaipur and Base Hospital, Mobile Surgical Unit, Jaipur (Rajasthan) from 1980 to 1988. Seven female patients were diagnosed and confirmed as tuberculosis of breast. Their age ranged from 17 to 50 years but majority were under 30. Duration of symptoms ranged from 6 months to 2 years. Main signs and symptoms of patients were as follows: multiple discharging sinus ( n = 3), (See [Figure:1]) painless lump in breast (n = 2), painful tender lump in breast (n = 1), breast ulcer (n = 1), axillary lymphadenopathy (same side) (n = 3) and pulmonary tuberculosis (n = 2).

In all the patients the diagnosis was made by biopsy of the lesion (open biopsy from sinuses or needle biopsy) with histological examination, (See [Figure:2]) detection of acid fast bacilli in discharge and culture Treatment was given with anti-tubercular drugs. Surgery was carried out in all cases and they were followed up.

::   Discussion and comments

Breast is rcmarkably resistant to tuberculosis, as are skeletal muscle and spleen[5]. The tuberculosis of breast is a disease of younger age group; uncommonly an older patient may present with a mass that mimics carcinoma, whereas the younger patient usually manifests sign of a pyogenic breast abscess[8].

In our series secondary tuberculosis of breast was present in two cases and in remaining 5 cases primary source was not traceable except the lesion in breast itself. Vassilakos[9] has cautioned against making diagnosis of primary disease, since it is probably quite rare and is diagnosed because the clinician is unable to detect the true nidus of disease. However, according to Hamit[5], in 60 per cent of cases it may not be possible to recover acid fast bacilli from any site, but the breast. Acid fast bacilli were recovered from only in 2 cases in our series, an incidence similar to that reported by Morgen[7]. In 1829, Cooper postulated that the breasts get secondarily involved by retrograde lymphatic extension from primary foci of disease in the lymph nodes of the mediastinum, axilla and parasternal and cervical region[10]. Supporting this hypothesis is the fact that axillary node involvcment occurs in 50 to 75 per cent of cases of tuberculosis mastitis. In our series same side axillary lymph node involvcment was present in 3 cases (43%).

There are three recognised modes of spread of the tubercle bacilli to the breast: direct, lymphatic and Haematogenous[1],[4]. Rarely, infected sputum can reach the underlying breast through superficial abrasions of the skin of the breast. In all cases bacilli infect the ducts and spare the lobules. Dilated ducts of the breast in pregnant and lactating women appear to be especially susceptible to infection[6]. Retrograde spread of infection from lymph node to the breast was observed in one of our patients in whom axillary lymph node preceded the appearance of a breast mass.

Tuberculosis of breast has been classified into five different types[6]: acute miliary tuberculosis mastitis, nodular tuberculosis mastitis, disscminated tuberculosis mastitis, selerosing tuberculosis mastitis and tuberculosis mastitis obliterans. Six of our cases can be classified as the nodular tuberculosis group and one as disscminated tuberculosis mastitis.

Early diagnosis is difficult, as the characteristic sinuses occur late in the course of the disease. In addition, presence of these sinuses is not the distinctive feature of tuberculosis, as several cases of non-tuberculosis granulomatous mastitis also present with sinuses. However, tuberculosis should be suspected in a patient who has a recurring breast abscess after adequate drainage on previous occasions. Multiple biopsies and detection of acid fast baccilli in wet film and culture is essential to establish final diagnosis. The patient who presents with a lump in the breast is clinically indistinguishable from a case of carcinoma of the breast. Mammographic appearances are very similar to fibroadenosis. In clinical presentation, aitinomycosis must also be considered, though this disease is rare in the breast.

Before the discovery of anti-tuberculosis drugs, surgeons performed mastectomies to treat mammary tuberculosis. Wilson and MacGregor[10] recommended simple mastectomy for most cases, due to development of local recurrence in three of their five patients following less severe procedures. However, today the combination of drug therapy and limited excision of diseased breast tissue is a method of choice[1],[4]. In our series, anti-tubercular chcmotherapy was given to all 7 cases. In 5 cases it was given in combination with excision of necrotic tissue and drainage of abscess. In one case simple mastectomy in combination with drug therapy was carried out.

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