What is the clinical presentation of breast involvement in extrapulmonary tuberculosis (TB)?

From the Guidelines

Breast involvement in extrapulmonary tuberculosis typically presents as a painless lump, which can mimic breast cancer, and diagnosis is confirmed through fine-needle aspiration cytology, histopathology, or PCR testing of breast tissue. The clinical presentation of breast involvement in extrapulmonary tuberculosis (TB) can be non-specific, making diagnosis challenging.

• Key symptoms may include a painless lump in the breast, which can be mistaken for breast cancer
• Other symptoms may be absent or non-specific, such as changes in breast texture or nipple discharge
• Diagnosis is often confirmed through a combination of imaging studies, fine-needle aspiration cytology, histopathology, or PCR testing of breast tissue 1. The treatment approach for breast TB is similar to other forms of extrapulmonary TB, with a focus on preventing drug resistance and ensuring effective eradication of the bacteria.
• The recommended treatment consists of an initial phase (2 months) with Isoniazid, Rifampicin, Pyrazinamide, and Ethambutol daily, followed by a continuation phase (4 months) with Isoniazid and Rifampicin daily 1.
• Specific dosages are:
  • Isoniazid: 5 mg/kg/day (max 300 mg)
  • Rifampicin: 10 mg/kg/day (max 600 mg)
  • Pyrazinamide: 25 mg/kg/day (max 2 g)
  • Ethambutol: 15-20 mg/kg/day (max 1.6 g)
• Treatment duration is typically 6 months total, but may be extended to 9-12 months in severe cases or if there's a slow response to therapy 1. It is essential to evaluate patients for concomitant pulmonary TB and other extrapulmonary sites of infection, as well as to monitor for potential side effects of treatment.
• Patients should be evaluated for concomitant pulmonary TB and other extrapulmonary sites of infection
• Monitoring for potential side effects of treatment, such as hepatotoxicity and visual disturbances, is crucial 1.

From the Research

Clinical Presentation

The clinical presentation of breast involvement in extrapulmonary tuberculosis (TB) can vary, but common symptoms include:

• Breast lump or mass, which is the most common presentation, reported in 75% of cases 2
• Pain, reported in 42% of cases 2
• Fever, reported in 28% of cases 2
• Axillary lymphadenitis, reported in 33% of cases 2
• Sinus or fistula, reported in 24% of cases 2

Diagnostic Challenges

Breast TB can be easily confused with breast cancer, suppurative abscess, and other causes of granulomatous mastitis, both clinically and radiologically 3, 4, 5. A high index of suspicion is required to diagnose breast TB, especially in endemic regions 5.

Diagnostic Methods

Various diagnostic methods can be used to diagnose breast TB, including:

• Fine-needle aspiration cytology (FNAC), which is an important diagnostic tool 2, 5
• Biopsy, which can be used to confirm the diagnosis 3, 2
• Acid-fast bacteria Ziehl-Neelsen stain, which can be used to detect TB bacteria 2
• Culture, which can be used to confirm the diagnosis 2
• Polymerase chain reaction (PCR), which can be used to detect TB DNA 2, 6

Treatment

The treatment of breast TB typically involves anti-tubercular chemotherapy, which is the standard of care 3, 2, 5. Surgery may be required in some cases, such as in patients who are refractory to medical treatment or who have a large abscess or fistula 3, 2.