DISCUSSION
Historically, clinical manifestations of BT have been observed within 1
year, but they range from months to years.11 BT
commonly affects women aged from 20-50 years,4,12which is equivalent to the higher prevalence of pulmonary tuberculosis
seen in a similar age women.13 In our report, the
patient was a 34-year-old woman presenting with symptoms for 2 months.
BT regularly presents as a lump14 in the central or
upper outer quadrant of the breast.15 In our patient,
the lump was present in the upper outer quadrant of the right breast.
Manifestation is inconsistent, frequently as a round nodular lump with
tissue induration, with fistula formation, but they are infrequently
connected with pain. Our patient had diffuse ulceration, pain, and a
lump in the right breast.
Tubercular ulcers over the breast skin and tubercular breast abscess
with or without discharging sinuses are even common forms of
presentation of BT.13 Our patient presented with a
unilateral draining sinus.
BT was classified earlier as: Nodular, disseminated, sclerosing,
obliterans, and acute miliary tubercular mastitis.14The sclerosing, obliterans, and miliary types are of historical
significance and currently BT could be reclassified as nodular,
disseminated, or abscess. The BT in our patient belonged to the abscess
variety.
BT lesions have no specific US findings and are visualized as
heterogeneous, hypoechoic, irregularly bordered with internal
echoes.16 Diagnosis is optimally based on the
confirmation of AFB in the breast tissue by ZN
staining.17 In this study, Doppler US showed features
of breast abscess, while FNAC showed epithelioid granulomas with AFB
positivity on ZN staining.
FNAC is a trustworthy diagnostic procedure, in which aspirated material
is subjected to staining for revealing AFB18 and
diagnosing BT.17 In BT cases, FNAC evaluation has
accurately diagnosed the cases as BT in 73% of the cases evaluated
using histopathology as having both epithelioid granulomas and
necrosis.19 In this study, histology revealed the
presence of Langhans giant cells, epithelioid cell granulomas, and
caseous necrosis; FNAC was diagnostically useful for BT.
Trepan biopsy showed a decent positive result. However, inci-/excisional
biopsy of breast lumps, ulcers, and sinuses, or a suspected tubercular
breast abscess cavity wall mostly diagnoses BT.17,19In this patient, an excision biopsy was suggested, but the patient and
her attendants refused the procedure.
Even though tests such as QuantiFERONâTB Gold-In tube have high
sensitivity (97.9%) and specificity (98.1%),20 there
are many limitations such as false-negative results in extrapulmonary
tuberculosis (28.8%)21 and inability to discriminate
latent tuberculosis from active tuberculosis
infection.22 In this study, FNAC evaluation paved the
way for an accurate diagnosis.
BT could show a diagnostic difficulty in radiological and
microbiological diagnosis, and consequently, high degree of suspicion
are required. BT is treatable with ATT,23 and surgical
intervention is needed in rare situations.