|Year : 2015 | Volume
| Issue : 2 | Page : 57-59
A rare entity of tubercular mastitis with chest wall extension in a male
Ved Prakash1, Virendra Kumar2, Ashwini Mishra1, Ajay Kumar Verma1, Ambrish Joshi1, Surya Kant1
1 Department of Pulmonary Medicine, King George's Medical University, Lucknow, Uttar Pradesh, India
2 Department of Medicine, Mahamaya Rajkiya Allopathic Medical College, Ambedkar Nagar, Uttar Pradesh, India
|Date of Web Publication||16-Jun-2015|
Ajay Kumar Verma
Department of Pulmonary Medicine, King George's Medical University, Lucknow - 226 003, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Tuberculosis (TB) is a chronic granulomatous inflammation involving usually the lung parenchyma and hilar lymph nodes. Extrapulmonary involvement is seen in about 15-20% of all cases of TB (EPTB). But breast TB is rare form of EPTB. We present a case of an immunocompetent male presenting with tubercular mastitis associated with chest wall extension. The rarity of this case lies in the site of involvement (chest wall), the way of presentation, and because of the immunocompetent status of the patient.
Keywords: Chest wall, mastitis, tuberculosis
|How to cite this article:|
Prakash V, Kumar V, Mishra A, Verma AK, Joshi A, Kant S. A rare entity of tubercular mastitis with chest wall extension in a male. J Assoc Chest Physicians 2015;3:57-9
|How to cite this URL:|
Prakash V, Kumar V, Mishra A, Verma AK, Joshi A, Kant S. A rare entity of tubercular mastitis with chest wall extension in a male. J Assoc Chest Physicians [serial online] 2015 [cited 2021 Jul 30];3:57-9. Available from: https://www.jacpjournal.org/text.asp?2015/3/2/57/158857
| Introduction|| |
Tuberculosis (TB) is a chronic granulomatous inflammation involving usually the lung parenchyma and hilar lymph nodes and barely involves musculoskeletal system. Extrapulmonary involvement is seen in about 15-20% of all cases of TB (EPTB). But breast TB is rare form of EPTB. In western countries, the reported incidence is less than 1% of breast lesions examined histologically.  But it accounts for 3% of surgically treatable breast conditions in India. It comprises of 3% of breast diseases and was five times less common than carcinoma of the breast. Though much more common in females, 4% of patients are males.  Clinical differentiation from breast abscess and malignancy is often difficult and a tedious job. It often requires various radiological, cytopathological, and histopathological evaluation. We hereby report a case of tubercular mastitis with chest wall extension without pulmonary involvement presenting as a lump in anterior chest wall which was resected considering it to be of neoplastic origin. This case highlights the possibility of any mass or lump to be of tubercular etiology, particularly in Indian subcontinent where the prevalence of TB is very high and is on surge. Identification of the cause as TB will prevent the patient from unnecessary surgical and psychological morbidity.
| Case Report|| |
A 60-year-old, nondiabetic, nonhypertensive male presented to us with complaint of swelling over the right mammary region for last 5 years. When he first observed the swelling it was pea sized, but because of patients shyness towards illness he did not consult any doctor. Four and a half years later it became a lump of size of about 30 × 25 cm, following which the patient visited a surgeon who did a lumpectomy considering it to be a neoplastic condition.
Post lumpectomy after 4 months, patient reported to us as the swelling started growing in size again. General physical examination was inconclusive. Routine blood examinations were within normal limit. Physical examination of chest revealed a cystic lump [Figure 1] of approximately 15 × 15 cm over the right mammary region associated with a scar mark extending 1 cm medial to nipple till anterior axillary line. Ten milliliter of pus was aspirated from the cystic part and was send for acid-fast bacilli staining and gram staining, both of which were negative. Contrast-enhanced computed tomography (CECT) thorax was done, which revealed a right chest wall swelling in the muscular plane, sparing the ribs and pleura [Figure 2] and [Figure 3]. Fine needle aspiration cytology (FNAC) and incisional biopsy from chest wall swelling was done, which showed granulomatous inflammation suggestive of tubercular mastitis [Figure 4]. Patient was started on antitubercular therapy (ATT); rifampicin 600mg, isoniazid 300 mg, ethambutol 1,000 mg, and pyrazinamide 1,500 mg daily dosing; and is improving gradually and is in our regular follow-up.
|Figure 2: CECT thorax showing a right chest wall swelling in the muscular plane, sparing the ribs and pleura CECT = Contrast-enhanced computed tomography|
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|Figure 3: CECT thorax showing a right chest wall swelling in the muscular plane, sparing the ribs and pleura|
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|Figure 4: Histopathology from chest wall swelling showing granulomatous inflammation suggestive of tubercular mastitis|
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| Discussion|| |
TB of breast is a rare form of TB. , It has been suggested that mammary gland tissue, like spleen and skeletal muscle, offers resistance to the survival and multiplication of the tubercle bacillus.  In western countries, the reported incidence is less than 1% of breast lesions examined histologically.  But it accounts for 3% of surgically treatable breast conditions in India. It comprises of 3% of breast diseases and was five times less common than carcinoma of the breast. Though much more common in females, 4% of patients are males.  The incidence of TB is quite high in India and so is supposed to be of breast TB. But unfortunately disease is commonly overlooked and misdiagnosed as carcinoma or a pyogenic abscess.  The breast may become infected by TB in a variety of ways: (i) Hematogenous, (ii) lymphatic, (iii) spread from contiguous structures, (iv) direct inoculation, and (v) ductal infection. The lymphatic spread of the disease from lungs to breast tissue is supposed to be via mediastinal lymph trunk (tracheobronchial, paratracheal) or internal mammary nodes.  Occasionally, spread may occur from contiguous structures such as infected rib, costochondral junction, sternum, shoulder joint, or a tuberculous pleurisy or via abrasions in the skin.  Most common presentation of breast TB is a lump  in the central or upper outer quadrant of the breast,  which can be explained probably as a result of tubercular bacilli spreading from axillary nodes to the breast. The lump is usually hard, fixed to either skin, muscle, or even chest wall;  and can be painful. An ulcer over the breast skin or an abscess with or without discharging sinuses are some other presentations.  Breast TB was first classified into five different types by Mckeown and Wilkinson.  These are: (i) Nodular tubercular mastitis, (ii) disseminated or confluent tubercular mastitis, (iii) sclerosing tubercular mastitis, (iv) tuberculous mastitis obliterans, and (v) acute miliary tubercular mastitis. The mammogram findings in breast TB cannot distinguish it from carcinoma breast and so is of limited value.  But ultrasonography of the breast can be useful in differentiating cystic from solid lesions without exposure to radiation  and is easily available also. The diagnostic yield of FNAC increases if ultrasound-guided FNAC is done. , CT scan can detect the extension of the abscess as well as the fixity of breast tissue with underlying chest.  An abscess has smooth marginated, nonhomogeneous, hypodense lesion with surrounding rim on contrast CT.  FNAC from the breast lesion is an important diagnostic tool of breast TB.  But the demonstration of acid-fast bacilli (AFB) on FNAC is not always easy, since it is a paucibacilliar disease; and the criteria for AFB to be seen microscopically, that is, number of AFB must be 10,000-100,000/ml of material  is seldom reached. Culture is gold standard for diagnosis of TB and the same is true for this case also, but the time required and frequent negative results  in paucibacillary specimens are important limitation. The rapid culture methods and the molecular techniques for early detection of mycobacterial growth (5-14 days as compared to 2-8 week with conventional methods), which are popular nowadays, for example, BACTEC, mycobacterial growth indicator tube (MGIT), and polymerase chain reaction (PCR) are highly useful in culture-negative specimens from paucibacillary forms of disease; and hence is the truth for this form of paucibacillary disease also. Histologically, tubercular mastitis is a form of granulomatous inflammation. Antitubercular drugs are mainstream of treatment.  No specific guidelines are available for the chemotherapy of breast TB per se. The regimen generally followed in the treatment of breast TB is similar to that used in pulmonary TB.  The outcome of the disease is very good if the ATT is taken properly and in correct dosages. Surgical intervention is sometimes required. Surgical intervention is reserved for aspiration of cold abscesses, and excision of residual sinuses and masses. In refractory cases with destruction of the breast, simple mastectomy may be performed. 
| Conclusion|| |
The diagnosis of musculoskeletal TB involving breast is often missed because it mimics other common diseases of breast like abscess and malignancy and requires high level of suspicion index. A complete history of illness, assessment of risk factors for immunocompromised state, good clinical and radiological examination, and a battery of tests including sputum, FNAC, biopsy, and culture for mycobacterium TB are crucial. Early initiation of antitubercular drugs associated with surgical intervention if required is appropriate management. Timely and early diagnosis can save the patient from unnecessary mental trauma regarding cancer and also unnecessary treatment for the same which can be so hazardous and toxic. Considering the fact that TB in any form is so common and rampant in this part of world and also the varsity of the disease in which it can present it is necessary to keep and rule out TB as a differential diagnosis in any case of breast lump or mass encountered in India.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]