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Breast

Inflammatory / infectious

Tuberculosis

Author: Reena Tomar, M.B.B.S., M.D.

Board of reviewers: Anna Biernacka, M.D., Ph.D.

Deputy Editor-in-Chief: Gary Tozbikian, M.D.

Last staff update: 19 December 2024 (update in progress)

Copyright: 2002-2024, PathologyOutlines.com, Inc.

PubMed Search: Tuberculosis breast

Table of Contents

Cite this page: Tomar R. Tuberculosis. PathologyOutlines.com website. https://www.pathologyoutlines.com/topic/breastTB.html. Accessed December 21st, 2024.

Definition / general

Breast is a rare extrapulmonary site of tuberculosis in young women in developing countries

Essential features

Primary or secondary infection of breast tissue by Mycobacterium tuberculosis (MTB)
Affects young, multiparous, lactating female patients in endemic regions or with HIV co-infection
Most common presentation is a breast lump that can mimic a pyogenic abscess or malignancy
Fine needle aspiration cytology (FNAC) or core needle biopsy (CNB) shows necrotizing granulomatous inflammation; MTB should be confirmed by microbiologic culture, Ziehl Neelsen (ZN) stain or nucleic acid amplification testing (NAAT)
Successfully responds to antitubercular therapy (ATT)

Terminology

Tuberculosis (TB) of the breast
Mammary tuberculosis
Tubercular mastitis

ICD coding

ICD-10: A18.89 - tuberculosis of other sites

Epidemiology

Accounts for 0.1% of breast lesions in Western countries (Indian J Surg 2015;77:1378)
Constitutes 3 - 4.5% of breast diseases in developing regions like Asia and Africa (Indian J Surg 2015;77:1378)
Can occur in any age, mostly 20 - 40 years, which parallels with a high incidence of pulmonary TB (Int J Mycobacteriol 2024;13:1)
Mostly affects young, multiparous, nursing women; less common in prepubescent and postmenopausal patients (Clin Case Rep 2024;12:e8826, Int J Surg Case Rep 2022;96:107242)
Risk factors: pregnancy, crowded areas, trauma (Int J Surg Case Rep 2022;96:107242)
Associated with immunosuppressed states, like human immunodeficiency virus (HIV) (Pan Afr Med J 2020;37:282)
Males are rarely affected (Postgrad Med J 2002;78:422, ANZ J Surg 2006;76:234, Cureus 2019;11:e4709)

Sites

Breast parenchyma and overlying skin
Usually unilateral; bilateral localization is rare (Clin Case Rep 2024;12:e8826)
Axillary lymph node involvement in 50 - 75% of cases

Pathophysiology

Breast tissue (like spleen or skeletal muscle) provides an infertile environment for the survival and multiplication of TB bacilli
Lactation makes it more susceptible to infection due to duct ectasia, increased blood supply and potential trauma to nipple
Breast TB can be primary (breast is the initial route or only site of infection) or secondary (involvement of breast from a tuberculous lesion elsewhere, usually lung) (Ann Thorac Med 2008;3:110)
Primary mammary TB (rare): direct inoculation of bacilli through lactiferous ducts, nipple lesion, skin abrasion
Secondary mammary TB (more common): multiple routes of infection, such as lymphatic, hematogenous (miliary) or contiguous spread (World J Surg 1995;19:379, Eur J Cardiothorac Surg 2002;22:324)
- Lymphatic retrograde extension from axillary nodes seems most likely, given the presence of ipsilateral axillary lymphadenitis in > 50% of cases
- Miliary TB with generalized hematogenous dissemination is rare
- Contiguous spread is from intrathoracic foci, pleura or chest wall

Etiology

Mycobacterium tuberculosis

Clinical features

Scrofulous swelling of the bosom is its first description by Sir Astley Cooper in 1829
Lump is the most common symptom (Indian J Surg 2015;77:1378)
Lumps can be mobile or fixed, mostly in the central or upper outer quadrant (Indian J Surg 2015;77:1378)
Can be painful or painless (Indian J Surg 2015;77:1378, Int J Mycobacteriol 2024;13:1)
Solitary or multiple confluent nodules
Nipple skin retraction can be seen (Indian J Surg 2015;77:1378)
Purulent nipple discharge is rare (Indian J Surg 2015;77:1378)
Can be misdiagnosed as a nonspecific abscess, fibroadenoma or carcinoma (Indian J Surg 2015;77:1378)
Can present with ulcer, fistula or abscess (Indian J Surg 2015;77:1378)
Peau d'orange or skin thickening over the lesion can be seen
Ipsilateral axillary lymphadenitis, with enlarged and then matted nodes frequently present
Constitutional symptoms (fever, malaise, weight loss, night sweats) < 20% of cases
Clinical classification (Indian J Surg 2015;77:1378, Int J Surg Case Rep 2022;96:107242)
Original classification by Mckeown et al. (Br J Surg 1952;39:420)
- Nodular caseous tubercular mastitis
  - Most common type; affects young female patients
  - Well circumscribed, slow growing, painless mass (may mimic fibroadenoma)
  - May progress to involve skin (which causes pain), ulcerate or form sinuses
  - Histologically: extensive caseation and little fibrosis
- Disseminated or confluent tubercular mastitis
  - Second most common type, caused by highly virulent MTB; occurs in older or immunodeficient patients
  - Numerous communicating tubercles involving entire breast, caseation common
  - Sinus formation and skin thickening with multiple ulcers.
  - Ipsilateral axillary lymph nodes are usually enlarged and matted
- Sclerosing tubercular mastitis (rare)
  - Extensive fibrosis, nipple retraction, no suppuration
  - Common in the involuting breast in older age; it mimics scirrhous carcinoma
- Tuberculous mastitis obliterans (rare)
  - Duct infection induces proliferation of lining epithelium and marked periductal fibrosis, leading to ductal occlusion and cystic dilations (cystic mastitis)
- Acute miliary tubercular mastitis (rare)
  - Part of a generalized disseminated form of TB with hematogenous spread

Diagnosis

FNAC is the investigation of choice (Indian J Surg 2015;77:1378)
- Gold standard for diagnosis: detection of M. tuberculosis by Ziehl-Neelsen staining for acid fast bacteria or organism isolation from the lesion on culture (Int J Mycobacteriol 2024;13:1)
TB mastitis is paucicellular / paucibacillary (Indian J Surg 2015;77:1378)
See Molecular / cytogenetics description

Laboratory

See Molecular / cytogenetics description

Radiology description

Ultrasound (US) / mammography / magnetic resonance imaging (MRI): not sensitive or specific but can give diagnostic clues (Int J Mycobacteriol 2024;13:1)
- US: heterogenous hypoechoic lesion, peripheral hypervascularization and edematous infiltration of the breast fat tissue or skin bulge (Int J Surg Case Rep 2022;96:107242, Insights Imaging 2021;12:19)
- Mammography: diffuse heterogenous limited opacity with microcalcifications and skin retraction at times (Int J Surg Case Rep 2022;96:107242, Insights Imaging 2021;12:19)
Chest Xray: normal (Int J Surg Case Rep 2022;96:107242)

Prognostic factors

Prognosis is good with antitubercular treatment (Pan Afr Med J 2020;37:282)

Case reports

24 year old woman with bilateral breast tuberculosis (Clin Case Rep 2024;12:e8826)
28 and 35 year old women presented with neoplastic-like tuberculosis of the breast (Int J Surg Case Rep 2022;96:107242)
31 year old Indian woman presented with tubercular mastitis mimicking a malignancy (Prague Med Rep 2020;121:267)
34 year old woman presented with rare extrapulmonary presentation of tuberculosis (Clin Case Rep 2023;11:e7728)
45 year old postmenopausal woman presented with coexistence of carcinoma and tuberculosis in 1 breast (J Transl Int Med 2015;3:32)
52 year old woman with breast tuberculosis presented with a painful lump (IDCases 2021;26:e01341)

Treatment

Often delayed due to difficulty in confirming the diagnosis
Antitubercular treatment (95% success rate with 6 month treatment) (Indian J Surg 2015;77:1378)
Surgical drainage of abscess may be needed
Breast abscess not responding to antibiotics should be evaluated for TB (Clin Case Rep 2024;12:e8826)

Clinical images

Images hosted on other servers:

Ulcer on the breast

Gross description

Nodular, indurated gray or tan tissue with yellow to white foci of caseous necrosis
Confluent nodular lesions with central cavitation grossly resemble necrotic carcinoma or suppurative abscess

Microscopic (histologic) description

Epithelioid cell granulomas
Langhans giant cells
Caseous necrosis
Lymphohistiocytic aggregates
Fibrosis can be seen
TB mastitis affects ducts more than lobules (Turk Patoloji Derg 2022;38:40, Indian J Surg 2015;77:1378)

Microscopic (histologic) images

Contributed by Reena Tomar, M.B.B.S., M.D.

Benign breast ductules and lymphohistiocytic infiltrate

Epithelioid cell granuloma

Epithelioid cell granuloma and Langhans giant cells

Epithelioid cell granuloma with lymphocytes

Caseous necrosis

Benign breast ductules and caseous necrosis

Ziehl-Neelsen stain

Cytology description

Smears from left breast are moderately cellular showing epithelioid cell granulomas, Langhans giant cells with caseous necrosis
Lymphoid cells with histiocytes are also seen
Clusters of ductal cells are seen in background
Reference: Turk Patoloji Derg 2019;35:128

Cytology images

Contributed by Reena Tomar, M.B.B.S., M.D.

Epithelioid cell granulomas with lymphocytes

Epithelioid cell granulomas

Positive stains

Stain for AFB is positive for rod shaped beaded pink Mycobacterium tuberculosis bacilli
Ziehl-Neelsen stain

Molecular / cytogenetics description

GeneXpert MTB RIF: cartridge based automated test that identifies Mycobacterium DNA and response to rifampicin (RIF) by nucleic acid amplification techniques (NAAT) (Turk J Med Sci 2023;53:744, IDCases 2021;26:e01341)
Molecular tests shown below are for tuberculosis in general and still in experimental phases for breast TB

	Advantages	Disadvantages
Polymerase chain reaction (PCR)	Rapid, high sensitivity and specificity; low sample requirement	Costly; may not confirm active infection
GeneXpert MTB / RIF	Rapid, detects rifampicin resistance, automated	Expensive; false negatives in low burden samples
Line probe assay (LPA)	Rapid multidrug resistance testing	Complex, costly; requires higher bacterial load
Loop mediated isothermal amplification (LAMP)	Fast, cost effective, minimal equipment needed	Limited validation for breast TB; not widely available
Interferon gamma release assay (IGRA)	Noninvasive; useful for detecting latent TB	Cannot confirm active TB; lower sensitivity in immunocompromised patients

References: J Clin Microbiol 2023;61:e0001723, Tuberc Respir Dis (Seoul) 2021;84:237, Jpn J Infect Dis 2020;73:272, IJTLD Open 2024;1:443, BMC infect Dis 2019;19:1069

Sample pathology report

Left breast, Trucut biopsy:
- Tubercular mastitis (see comment)
- Microscopy: Section shows benign breast ductules with fibrocollagenous stroma with adjacent mature adipose tissue with the presence of multiple well defined epithelioid cell granulomas, caseous necrosis and Langhans giant cells. Lymphohistiocytic infiltrate is also seen. Ziehl-Neelsen stain for AFB is positive.
- Comment: Advise follow up after antitubercular treatment.

Differential diagnosis

Breast carcinoma:
- Clinically can mimic malignancy due to a painful solid lump
Pyogenic / nonspecific abscess:
- Clinically presents as an ulcer, abscess with fever, which is also seen in tubercular mastitis
- Absence of TB bacilli on Ziehl-Neelsen stain can lead to misdiagnosis of pyogenic abscess
- Pyogenic abscess will respond to antibiotics, which is ineffective in tubercular mastitis
Pathological findings of granulomatous inflammation encompass a wide range of differential diagnoses, such as
- Sarcoidosis:
  - Noncaseating granulomas with other features like asteroid bodies
  - Necrosis is rarely seen
- Lobular granulomatous mastitis:
  - Noncaseating granulomas
  - Absence of TB bacilli on Ziehl-Neelsen stain
  - Treatment includes steroids, which may flare up tuberculosis
- Granulomatous reaction to tumor, leprosy, cat scratch disease, syphilis, histoplasmosis, Cryptococcus, Crohn's disease

Board review style question #1

A 30 year old woman presented with a 2 x 2 cm firm, indurated mass in her right breast. She has associated nipple retraction and no axillary lymphadenopathy with a history of tuberculosis treated 5 years ago. A biopsy shows granulomatous inflammation and PCR is positive for Mycobacterium tuberculosis. Which of the following diagnoses is most likely?

Granulomatous mastitis
Invasive ductal carcinoma
Primary tuberculous mastitis
Secondary tuberculous mastitis

Board review style answer #1

D. Secondary tuberculous mastitis arises from an existing tuberculosis focus elsewhere in the body, commonly in the lungs. The patient's history of tuberculosis, granulomatous inflammation and positive PCR suggest a secondary spread rather than primary inoculation. Answer C is incorrect because the patient has a history of tuberculosis. Answer A is incorrect because a history of tuberculosis was indicated and PCR is positive for Mycobacterium tuberculosis. Answer B is incorrect because there are no malignant cells seen in the biopsy.

Comment Here

Reference: Tuberculosis

Board review style question #2

A 22 year old nulliparous woman presents with a mobile breast lump with a focal abscess on the skin and a fever for 10 days. The patient comes from a crowded community. She is not responding to a week of antibiotics. Chest Xray was normal and erythrocyte sedimentation rate (ESR) was raised. A Trucut biopsy demonstrates features shown in the image above. What is the probable diagnosis?

Breast carcinoma
Cystic neutrophilic granulomatous mastitis (CNGM)
Pyogenic abscess
Tubercular mastitis

Board review style answer #2

D. Tubercular mastitis. The patient is not responding to antibiotics and comes from a crowded environment with constitutional symptoms of tuberculosis. Answer C is incorrect because the patient is not responding to antibiotics. Answer A is incorrect because the lump is mobile and the patient is clinically presenting with symptoms of tuberculosis. Answer B is incorrect because CNGM mainly occurs in multiparous women and responds to antibiotics.

Comment Here

Reference: Tuberculosis

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