Primary breast tuberculosis

Clinical History

A 27 year old Philippine woman presented with a palpable mass located in her right breast. She had no family history of breast carcinoma and underwent two bilateral lumpectomies for fibroadenomas, five years before. She reported no pulmonary or other diseases. Mammographic and ultrasonographic findings were indicative of breast carcinoma.

Imaging Findings

On examination, she had a breast mass in the right retroareolar region with not well defined contours. The mammogram showed an irregular large retroareolar mass lesion (Fig 1,2). On ultrasound, the lesion was ill defined, hypoechoic, and vascularised on colour-Doppler (Fig 3a, b), with two hypoechoic, atypical lymph nodes in the right axilla (Fig 4a,b). Then, a core needle biopsy was performed on the right breast lesion and revealed granulomatous inflammation and some atypical cells that could not exclude the possibility of malignancy; also a fine needle aspiration was done on nodes and revealed no atypical cells.
A dynamic MRI examination was performed; the T2 weighted fat sat images revealed enlarged nodes in right axilla and a hyperintensity area in the retroareolar space (Fig 5a). A contrast-enhanced MRI showed a large retroareolar mass like enhancement with a wash-in uptake >100% (Fig 5b,c). A resection of the right breast mass was performed. The hystopathologic evaluation of the specimen confirmed granulomatous chronic inflammation.
One year later a fixed plaque in the retroareolar and para-areolar region of the right breast developed again associated with a surgical wound fistula with yellowish material. Ultrasound study revealed a communication between wound and ducts (Fig 6a-d).
The infectological evaluation allowed making diagnosis of primary breast tubercolosis. Chest x-ray and CT showed absence of the pleural or pulmonary lesions suspicious (Fig 7, 8).

Discussion

The incidence of tuberculosis is rising in developing and developed countries with global epidemic about 2 million deaths and 9 million new cases of the disease a year. Besides, rare extra-pulmonary manifestations of the past are seen more often nowadays [1]. Although the breast tuberculosis is a rare entity, its overall incidence is about 0.1% of all breast lesions, while in developing countries it represents about 3.0% of surgically treated breast lesions [2, 3]. Breast tuberculosis may be primary, when is not demonstrable the tuberculosis focus existence and that it is probably a result of infection of the breast through abrasions or through openings of the ducts in the nipple or it may be secondary to a lesion elsewhere in the body and develops by either direct extension, retrograde lymphatic dissemination from the affected axillary lymph nodes or rarely, from pulmonary disease [4, 5]. Typical symptoms of tuberculosis as fever, weight loss, night sweats, or failing of general health, are frequently absent. It presents generally as lump in the upper outer quadrant of the breast. The lump is often mistaken for a carcinoma, being irregular, hard, fixed or painful. Sometimes, breast tuberculosis presents as abscess with or without discharging sinuses. There are 3 clinical varieties of breast tuberculosis: nodular, disseminated, and sclerosing. The nodular form is characterized by a circumscribed, caseous lesion that often mimics a fibroadenoma or carcinoma. The disseminated variety is characterized by multiple confluent foci which cause multiple ulcerations; this form simulates inflammatory breast cancer on mammogram. Sclerosing tuberculosis with slow growing and affect involuting breasts of older women [4, 6]. Breast tuberculosis is often misdiagnosed, especially in countries like ours where the prevalence of the disease is very low, and the patient is subjected to numerous investigations before a definitive diagnosis is made. Mammography and ultrasonography are unreliable in distinguishing tuberculosis infection from carcinoma. The main mammographic findings are dense breast parenchyma with or without an associated ill-defined mass-like density, not specific for diagnosis. It usually appears as ill defined heterogeneous hypoechoic lesion, with the involvement of axillary lymph node, on ultrasonography. Sometimes, ultrasonography shows a beak like fistulous connection between retromammary abscess and chest wall, but also these findings are non-diagnosed for tuberculosis [7]. The main methods of diagnosis are by bacteriological cultures of aspirates from the lesion and histological examination of tissues obtained by biopsy. At histological examination the lesion appear as granulomatous inflammation, but many conditions are characterized by this tissue reaction as sarcoidosis, same fungal infections and granulomatous reactions to extraneous material, just as we thought in this case, since the patient underwent two lumpectomy years ago. Also other radiological imaging modalities as MR are often not conclusive [4, 7]. Medical treatment is based on four drugs (rifampicin, isoniazid, pyrazinamide, ethambutol) for 6 months. Surgical intervention is reserved for aspiration of abscesses, and excision of residual sinuses and masses. In refractory cases with destruction of the breast, simple mastectomy may be performed [8].

Differential Diagnosis List

Final Diagnosis

Primary breast tuberculosis

URL:	https://eurorad.org/case/7542
DOI:	10.1594/EURORAD/CASE.7542
ISSN:	1563-4086