Case Report

Mammary Tuberculosis in a Young Female Presenting as

Voluminous Abscess - A Case Report
Surg Capt S C Patra (Retd)", Dr. Swapnil Tople"

Introduction
Mammary
Tuberculosis is an extremely rare entity
and gain great significance due to its mistaken identity
with chronic pyogenic abscess and breast cancer. It
was discovered for the first time by Cooper in 1829
(l). It is scarcely reported even in countries with a
high incidence of tuberculosis infection. This is
explained by a noticeable resistance of the mammary
tissue to the mycobacterium
tuberculosis
(2).
Mammary tuberculosis presents a diagnostic problem
on radiological and microbiological investigations.
Diagnosis of breast tuberculosis therefore remains a
challenge for the clinician. Anti-tubercular therapy with
or without minimal surgical intervention forms the
mainstay of treatment. We report a case of mammary
tuberculosis in a young female presenting as a
voluminous tubercular abscess and mimicking the
clinical form of a pyogenic breast abscess.

Case Report
A 18 years old female presented with a rapidly
growing lump in the left breast of 2 weeks duration.
(Fig 1)
-

The patient had a past history of pulmonary

tuberculosis and had taken a complete course of antitubercular therapy. Physical examination revealed an
afebrile and normotensive patient with no pallor,
icterus or generalized lymphadenopathy.
Breast
examination confirmed a 15 x 14 x 4 cm lump involving
the left breast. There was no local warmth or
tenderness. The lump had a smooth surface with welldefmed margins and was variegated in consistency.
It was neither fixed to the skin nor to the underlying
muscle. Left nipple was retracted and the overlying
skin was stretched with few visible dilated veins. There
was a palpable 1.5 em single, firm, non-tender and
mobile.axillary lymph node.
A clinical diagnosis of mammary abscess was
made. Laboratory work up revealed raised ESR with
normal leucocyte count and normal liver and renal
function test results. Chest X-ray was normal. Ultra
sonography (USG) breast revealed evidence of left
breast abscess with thick pyogenic debris and a
reactive
axillary lymph node in left axilla.
Mammography revealed evidence of a well-defmed
mass lesion with liquid content. Fine needle aspiration
cytology (FNAC) of axillary lymph node was
reported as reactive lymphadenitis.
Diagnostic
aspiration of left breast mass was undertaken which
revealed thick pus and was sent for microscopy,
culture and Z-N staining. Gram staining revealed
Staphylococcus aureus for which the patient was
treated with amoxicillin and clavulanate potassium
empirically. Considering the sonography, aspiration
and Gram staining report, incision and drainage of
the breast abscess was done and approximately 300
ml of pus drained which was sent for microscopy,

Fig 1: Clinical presentation of tubercular abscess of left breast

"Professor, "Senior Resident, Department of General Surgery, ESI Post Graduate Institute Medical Science &
Research, Mahatma Gandhi Memorial Hospital, Parel, Mumbai-4000l2.
"Corresponding author: Email-drscpatra@gmail.com.
Mob: (+91)9869859992
Jour. Marine Medical Society, 2014. Vol. 16. No.1

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culture and Z-N staining. Breast tissue scraping from

abscess cavity wall was sent for histo-pathological
examination. Z-N staining revealed Acid fast bacilli.
Patient received CAT II AKT to which she responded
well. Followup at 2 months
revealed
a
symptomatically better patient with a well healed
wound.

Discussion
In developing

countries like India where

Tuberculosis (TB) is endemic, TB of the breast
accounts for only 3% of treatable breast conditions
[3]. Tuberculosis is caused by Mycobacterium
tuberculosis and affects primarily the lungs. Breast
TB could be primary when breast lesion is the only
manifestation ofTB or secondary when demonstrable
TB lesion is present elsewhere in the body (4)
However, it is now increasingly accepted that breast
TB is almost invariably secondary to a lesion
elsewhere in the body (5).
The breast may be infected by several ways. The
route of spread includes haematogenous, lymphatic,
from contiguous structures, direct inoculation, and
ductal infection. Of these the most accepted view of
spread of infection is centripetal lymphatic spread,
from lungs to breast tissue, via the tracheobronchial,
para-tracheal, mediastinal lymph trunk and internal
mammary nodes. Infection through skin abrasions,
through main ducts of nipple or retrograde spread
from axillary lymph node may result in formation of
a mammary abscess.

,, ,,
:

I:
I.

Mammary tuberculosis commonly affects young

women of reproductive age group. It is relatively
uncommon in pre-pubescent females and elderly
women. Pregnant
and lactating
women are
predisposed to trauma making it more susceptible to
tuberculatinfection.
Breast tuberculosis is rare in
males.
Mammary tuberculosis' usually presents as a
unilateral disease. Bilateral involvement is uncommon
3 %). Lump in breast with or without axillary lymph
nodes is the most common presentation. Mammary
tuberculosis
may present as peau d'orange
appearance of skin, ulcers, purulent nipple discharge,
and breast abscess with or without discharging sinus
(5).
MT was recently classified in to 3 categories by
Tewari & Shukla (2) : nodulocaseous tubercular
56

mastitis, disseminated/confluent tubercular mastitis,

and tubercular breast abscess. Our case falls in the
last category. Various test are useful in the diagnosis
and evaluation of patients with mammary tuberculosis.
Mantoux test does not offer any defmitive diagnosis,
but confirms exposure of patient to tubercular bacilli.
Chest X -ray may show evidence of active or healed
tuberculous lesions in the lung. Mammography, is not
helpful especially in young women, due to high density
of breast tissue where as in elderly women,
mammography findings are generally indistinguishable
from Breast Carcinoma. USG generally shows a
hypoecheoic lesion in 60% of patients and it may
sometimes identify a sinus tract in tuberculous mastitis.
FNAC may not be able to detect the responsible
pathogen itself, but is helpful in detecting the presence
of epitheloid cell granulomas and necrosis, leading to
a defmitive diagnosis in up to 73% of cases of
\mammary tuberculosis (7). In tubercular mammary
abscess, the only essential element to confmn the
diagnosis is histopathological test of the sample
obtained after the surgery, as in our case, or biopsy
of abscess wall. CT and MRI breast are used to
evaluate the extension of the lesion beyond the breast,
principally towards the thoracic wall. The gold
standard for diagnosis of breast tuberculosis is
detection of Mycobacteriun tuberculosis by Z-N
staining or by culture (4). Histo-chemistry, however
is not practical and culture of Mycobacteriun
tuberculosis has limitations due to delay in obtaining
the final result and possibility of false negative results
in pauci-bacillary samples. PCR is highly sensitive
for diagnosis of mammary tuberculosis. It is especially
recommended in cases with negative culture results.
Histopathology of the lesion identifies a chronic
granulomatous inflammation with caseous necrosis
and Langhan's type giant cells, contributing to
diagnosis in majority of cases. The principal
differential diagnosis of mammary tuberculosis is
breast carcinoma and other conditions such as fatty
necrosis, plasma cell mastitis, peri-areolar abscess,
idiopathic granulomatous mastitis, actinomycisis and
blastomycosis are to be considered. (4)
Anti-tuberculous therapy with 2HRZE+4HR
forms the mainstay of treatment (5). Surgical
intervention is required for aspiration or drainage of
abscesses or excision of sinuses or masses. Simple
mastectomy, most often without axillary lymph node
dissection is reserved for. cases with extensive
Jour. Marine Medical Society. 2014, Vol. 16, No.1

disease, causing a large painful ulcerated

involving entire breast. (6)

mass

Conflicts of interest
All authors have none to Declare.

Conclusion
A diagnosis of mammary tuberculosis should be

References
1.

Cooper: Illustrations of the Diseases of the Breast. Part 1.

London: Longman, Rees, Orme, Brown, and Green 1829:
73.

2.

Tewari M., Shukla H.S.: Breast tuberculosis: Diagnosis,

clinical features & management. Indian J Med Res, 2005,
122: 103-110.

3.

Khanna R, Prasanna GV, Gupta P, Kumar M, Khanna S,

Khanna AK: Mammary tuberculosis: report on 52 cases.
Postgrad Med J 2002; 78: 422-424.

4.

Spyridon M, Dionysia L, et al. Breast tuberculosis:

Diagnosis, management and treatment. Int J Surg Case Rep.
2012; 3(11) : 548-550.

5.

Surendra K Sharma, Alladi Mohan et al. Tuberculosis, Second

edition 2009:29;434-40.

6.

Imtiaz W, AliM.L., et al. Secondary Tuberculosis of Breast:

Case Report.ISRN Surg, Vo12011, Article lD 52936j1,.

7.

Young Female Presenting as Voluminous Abscess. J. Marine

Kakkar S., KapilaK., Singh M.K., VermaK. : Tuberculosis

of the breast. A cytomorphologic study. Acta Cytol,2000,

Medical Society, 2014, 16 (1): 55-57.

44: 292-296.

made in a patient with or without a past history of

tuberculosis, if the patient presents clinically with a
lump and imaging studies like mammography and
USG shows an indeterminate mass. This case report
concludes that clinical and radiological signs are
unreliable and mammary tuberculosis has to be
considered in the differential diagnosis of breast
lesions, especially in breast abscesses with or without
discharging sinuses and more so if the patient belongs
to the high-risk population or lives in an endemic
region.

How to cite the article

Patra S C, Dr Tople Swapnil. Mammary Tuberculosis

in a

Source of support
Nil

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