What are the guidelines for treating breast tuberculosis (TB) in India?

Guidelines for Treating Breast Tuberculosis in India

The standard treatment for breast tuberculosis in India follows the same principles as pulmonary tuberculosis, with a 6-month regimen consisting of 2 months intensive phase (HRZE) followed by 4 months continuation phase (HR).

Diagnosis

• Breast tuberculosis presents with:

  • Unilateral breast mass (may mimic carcinoma)
  • Discharging sinuses
  • Cold abscess
  • Non-healing ulcer
  • May occur in lactating mothers 1

• Diagnostic approach:

  • Tissue diagnosis is essential through excisional biopsy, core biopsy, or FNAC
  • Look for caseating granulomas on histopathology
  • AFB smear and culture (though often negative)
  • Mantoux test (may be positive)
  • Assess for concurrent pulmonary TB 1, 2

Treatment Regimen

First-line Treatment

1. Intensive Phase (2 months):

   • Isoniazid (H)
   • Rifampin (R)
   • Pyrazinamide (Z)
   • Ethambutol (E)

2. Continuation Phase (4 months):

   • Isoniazid (H)
   • Rifampin (R) 3, 4

Dosing Schedule

• Daily dosing is preferred for both intensive and continuation phases
• Alternatively, thrice-weekly dosing can be used under directly observed therapy (DOTS) as implemented by the Revised National TB Control Program 4

Duration of Treatment

• Standard 6-month regimen (2HRZE/4HR) is sufficient for most cases of breast tuberculosis 5
• Treatment may be extended in cases with poor response or extensive disease

Surgical Management

• Surgical intervention is often required alongside antituberculous treatment:

  • Drainage of cold abscesses
  • Excision of necrotic tissue
  • Removal of infected breast tissue 1, 6
  • Wide excision biopsy for lumps less than 5 cm
  • Core biopsy for lumps more than 5 cm 1

• Studies show that despite antituberculous treatment, surgical management is required in approximately 70% of cases 1

Monitoring and Follow-up

• Monthly clinical evaluations during treatment
• Monitor for adverse effects:
  • Hepatotoxicity (baseline and regular liver function tests)
  • Optic neuritis (baseline visual acuity for ethambutol)
  • Peripheral neuropathy (consider prophylactic pyridoxine) 3

Special Considerations

Pregnancy

• All first-line drugs except streptomycin can be used during pregnancy
• Prophylactic pyridoxine (10mg/day) is recommended 4

HIV Co-infection

• Standard short-course chemotherapy is indicated
• Be alert for paradoxical response or immune reconstitution phenomenon
• Consider drug interactions with antiretroviral therapy 4

Drug-Resistant TB

• Never add a single drug to a failing regimen 7, 3
• If drug resistance is suspected:
  • Add at least 2 drugs to which the organism is likely susceptible
  • Consult with TB expert
  • Obtain drug susceptibility testing 7

Common Pitfalls to Avoid

1. Misdiagnosis as breast carcinoma or pyogenic abscess 2
2. Adding a single drug to a failing regimen 7, 3
3. Inadequate surgical debridement when indicated
4. Failure to ensure adherence to the complete treatment regimen
5. Inadequate monitoring for adverse effects 3

Referral Criteria

Management of MDR TB should be referred to specialized units with facilities for quality-controlled drug susceptibility testing and experience in handling such cases 4.

Remember that breast tuberculosis, while rare, should be considered in the differential diagnosis of breast masses in India, where TB is endemic 2.