JBR–BTR, 2008, 91: 54-57.
PRIMARY MAMMARY TUBERCULOSIS PRESENTING AS A VOLUMINOUS ABSCESS B. Borens-Fefer1, C. Engohan-Aloghe3, J.C. Noël3, Ph. Simon2, D. Bucella2, R. Boutemy1 We present a case of primary mammary tuberculosis (MT), an extremely uncommon pathology, revealed by a voluminous tubercular abscess mimicking a recurrent pyogenic abscess. It was correctly diagnosed after a while because of partial response to antibiotics with a disappearance of the diffuse inflammatory components explained by the effect held concurrently by some antibiotic on a probable staphylococcic superinfection and its bactericidal effect against BK. This is the most common presentation of the mammary forms of the MT and the diagnosis particularly makes sense in this case matching several risk factors: female gender, lactation, young age, and origin from an endemic area. Furthermore the persistence of an abscess after a well driven medical treatment should always make search the presence of BK. Key-words: Breast, abscess – Tuberculosis, soft tissues.
Mammary Tuberculosis (MT) is an extremely rare disease. It was discovered for the first time by Cooper in 1829 (1). 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). Its primary form is even more infrequent. We are reporting a case of primitive MT characterized by a voluminous tubercular abscess and taking the clinical form of a breast pyogenic abscess which acute diffuse inflammatory component receded through antibiotic therapy. Case report A 20-year old woman hailing from Maghreb, lactating for one year, was brought to the emergency services because of a voluminous inflammatory mass on her right breast. The disease had started five months previously. An antibiotic therapy (Amoxicilline 1750 mg/d and Clavulanate 250 mg/d) had been administered for ten days, leading to a reduction of the inflammatory signs, though the mass persisted. The mass was punctured three times by the general practitioner. The discharge was each time purulent but bacteriologically negative. Clinically the right breast was oedematous, hyperemic and warm to palpation with a large painful palpable nodular lump in the upper outer quadrant up to the armpit. The patient was not pyretic.
Fig. 1. — Ultrasonography demonstrating a well-encapsulated heterogeneous collection.
Echography of the right breast revealed cutaneous oedema, fat infiltration, dilation of the lympathics and a well-encapsulated heterogeneous 10 cm collection (Fig. 1) as well as two adjoining adenopathies at the source of the armpit. The diagnosis of abscessed mastitis was made. An antistaphylococcal (Flucloxacilline) and antiinflammato-
From: Department of 1. Radiology, 2. Gynecology, 3. Anatomopathology, ULB, Erasme Hospital, Brussels, Belgium. Address for correspondence: Dr B. Borens, Dpt of Radiology, ULB, Erasme Hospital, 808, Route de Lennik, B-1070 Brussels, Belgium. E-mail:
[email protected]
ry treatment was given for 14 days. Blood test at the time of admission failed to reveal any inflammatory sign. Two weeks later the diffuse inflammatory mammary signs had subsided. However a wide collection was still present. Subsequently, 150 cc of yellowish lactescent liquid, which cytobacteriological analysis was negative, was aspirated. X-ray mammography revealed a well-defined mass with a diameter of 13 cm, of liquid content and with a partially fatty density in the super outer quadrant and at the base of the right armpit (Fig. 2 A,B). The
PRIMARY MAMMARY TUBERCULOSIS — BORENS-FEFER et al
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B
Fig. 2. — X-ray mammography with CC (A) and MLO (B) view demonstrating a well-defined mass, of liquid cotent with a partially fatty density in the upper outer quadrant and at the base of the right armpit.
monitoring echography showed an encapsulated heterogeneous liquid mass and absence of the inflammatory cutaneous and sub cutaneous signs, and persistence of two axillary adenopathies adjoining the mass. The hypothesis of a voluminous over-infected galactocele was presented and it was decided on surgical resection of the mass (Fig. 3). Histopathology revealed a necrotic giant cells granuloma of the mass and both adenopathies (Fig. 4). Bacteriological research for mycobacteria confirmed the presence of mycobacterium tuberculosis. The diagnosis of mammary tuberculosis was thus established. A chest X-ray was done to exclude primary pulmonary tuberculosis and revealed negative. Treatment with Rifampicine 600 mg/d, Ethambutol 1200 mg/d, Isoniazide 300 mg/d, Pyrazinamide 2000 mg/d was initiated awaiting the results of the antibiogram. This latter revealed a multisensitive mycobacterium tuberculosis, this is why the
Ethambutol was stopped and we kept the three other antibiotics for a total duration of 6 months. Afterwards Rifampicine was given for another 4 months. On the other hand we suggested the patient to go for a tuberculin skin test and a chest X-ray of her child (2). Discussion MT is rare. In the high tubercular endemic countries like India, the incidence represents 3 to 4.5% of the mammary pathologies (3). In the Western countries, with a lower tubercular incidence, it represents less than 0.1% of the mammary lesions examined via histology (2, 4). MT was recently classified in 3 categories by Tewari & Shukla (2): nodulocaseous tubercular mastitis, disseminated/confluent tubercular mastitis, and tubercular breast abscess. Our case falls in the last category. Usually the primary or secondary character of MT is assessed at the
time of general examination for the disease (2, 5, 6). By default MT is classified as primary when no tubercular focus exists elsewhere in the body. Our patient did not show any typical symptom of the disease (fever, cough, night sweats, weight loss) and was not in contact with people suffering from tuberculosis. Her chest was actually radiographed to locate a primary focus which was eventually not found. This confirmed the previous diagnosis of a primary MT. MT is uncommon because the mammary gland tissue, like the spleen and skeletal muscle, offers resistance to the survival and multiplication of the tubercle bacillus. Infection of the breast can occur as the result of various ways: direct, haematogenous (extremely rare even in debilitated patients), ductal infection, spread from contiguous structures and, most of the time, lymphatic (2). The diagnosis of the MT is difficult to establish because it is a sum of non-specific symptoms and imaging
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JBR–BTR, 2008, 91 (2)
Fig. 4. — Microscopic view (H.E.S. 200) showing a necrotic giant cells granuloma. Fig. 3. — Macroscopic view of the mass, at the top the abscess and at the bottom the two adenopathies.
findings (6, 7). It has been mentioned above that several types of MT exist, and they are given different radiographic translations. In this case, the ultrasonography realized in the acute inflammatory phase showed cutaneous oedema with infiltration of the fat and lymphatic dilatation, and a well defined heterogeneous 10 cm collection with two axillary adenopathies. The mammography, conducted after the administration of antistaphylococcal antibiotherapy and reduction of the inflammatory symptoms, revealed a well-defined mass with a diameter of 13 cm, partially liquid and partially with a fatty density in the upper outer quadrant of the right breast at the base of the armpit. A clinical presentation mimicking a pyogenic abscess is well known but in our case the diagnosis was delayed because of partial clinical response of inflammatory peaks to classical antibiotics. This could be explained by a staphylococcic superinfection – supported by the breastfeeding – for which AmoxicillineClavulanate is effective. AmoxicillineClavulanate also has an early bactericidal activity against mycobacterium tuberculosis (8) and both activities could cumulate. However the persistence of the voluminous mass even after the acute inflammatory symptoms, and several punctures with negative bacteriologic cultures, excluded the diagnosis of pyogenic abscess. Therefore, during a lactating phase, the diagnosis of an infected
galactocele, with linked axillary adenopathies, was evoked. Other diagnoses namely actinomycosis, idiopatic granulomatous mastitis or tubercular mastitis were probable (6); the latter was demonstrated through the histopathological analysis on the surgical sample of the mammary lesion and confirmed bacteriologically. Some clinical elements and risk factors help in the establishment of the diagnosis: female gender, lactation, young age, multiple maternities and origin from an endemic area (2, 5, 6). Our patient matched with this profile, with 4 risk factors: woman from Morocco, 20 years old and lactating. In front of these risk factors, it should always be asked for research and culture of mycobacterium tuberculosis besides the usual germs. Furthermore the persistence of an abscess after a well driven medical treatment should always make search for the presence of BK. Fine needle aspiration cytology (FNAC) remains a reliable method to diagnose MT, as 73% of the MT show epithelioid cell granulomas with necrosis (9). However in tubercular mammary abscess FNAC produces an inflammatory discharge. In such a case, the only essential element to confirm the diagnosis is histopathological test on surgical abscess sample, as in our case, or biopsy of abscess wall (2). The diagnosis was confirmed with the presence of mycobacterium tuberculosis in the bacteriological
culture. Despite lots of false negative bacteriological reports linked to samples which contained too few bacilli and a long culture time (2), it allowed an antibiogram that helped to adapt the anti-tubercular treatment. There is no common agreement regarding the MT treatment (2). The medical treatment consists of the same combination of antitubercular drugs as in pulmonary tuberculosis. Surgery depends on the type of lesion according to Tewari and Shukla’s classification, and size of the lesions. In instances of large abscess, like our patient (12 x 5 x 2 cms), combination of incisional biopsy and of complete antitubercular treatment seems to be the best option. References 1.
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Cooper: Illustrations of the Diseases of the Breast. Part I. London: Longman, Rees, Orme, Brown, and Green 1829: 73. Tewari M., Shukla H.S.: Breast tuberculosis: Diagnosis, clinical features & management. Indian J Med Res, 2005, 122: 103-110. Gupta V., Mohan H., Jain P., Singh S., Singla N.: Tuberculous mastitis: A report of two cases in elderly females. Jpn J Infect Dis, 2006, 59: 279-280. Kalaç N., Ozkan B., Bayiz H., Dursun A.B., Demirag F.: Breast Tuberculosis. The Breast, 2002, 11: 346-349. Chauhan A., Kakkar S., Mahapatra S.: Mammary Tuberculosis – A Case Report. MJAFI, 2006, 62: 385-386.
PRIMARY MAMMARY TUBERCULOSIS — BORENS-FEFER et al 6. Akcakaya A., Eryilmaz R., Sahin M.: Tuberculosis of the Breast. The Breast J, 2005, 11: 85-86. 7. Mnif Z., Mzeghani S., Ayadi W., Mnif J., Ayadi K., Mahfoudh K.H.B., Siala I., Zouari S., Daoud E., Kechaou
M.S.: Mastite Tuberculeuse : Aspects en Imagerie à propos de 7 cas. J Le Sein, 2004, 4: 299-305. 8. Chambers F., Kaocagöz T., Sipit T., Turner J., Hopewell P.C.: Activity of Amoxicillin/Clavulanate in patients
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with Tuberculosis. Clinical Infectious diseases, 1998, 26: 874-877. 9. Kakkar S., Kapila K., Singh M.K., Verma K.: Tuberculosis of the breast. A cytomorphologic study. Acta Cytol, 2000, 44: 292-296.
