What is the recommended treatment for a woman of reproductive age with TB (tuberculosis) mastitis from a region with high TB prevalence?

Treatment of TB Mastitis in Women of Reproductive Age

Treat TB mastitis with the standard 6-month short-course regimen: isoniazid, rifampin, pyrazinamide, and ethambutol for 2 months, followed by isoniazid and rifampin for 4 months, with consideration for surgical intervention if medical therapy fails. 1, 2, 3, 4

Initial Treatment Regimen

The standard four-drug regimen is essential for all forms of extrapulmonary TB, including TB mastitis:

• Start with isoniazid (5 mg/kg up to 300 mg daily), rifampin (600 mg daily), pyrazinamide (15-30 mg/kg daily), and ethambutol (15-25 mg/kg daily) for the first 2 months 1, 2, 3, 4
• Continue with isoniazid and rifampin alone for an additional 4 months (total 6 months) 1, 2, 3
• Some experts recommend extending treatment to 9 months for extrapulmonary TB, though evidence for this specific extension in breast TB is limited 1

The fourth drug (ethambutol or streptomycin) is mandatory unless your community has documented isoniazid resistance rates <4% 2, 3

Special Considerations for Women of Reproductive Age

If Pregnant or Planning Pregnancy:

• Use isoniazid, rifampin, and ethambutol for 2 months, then isoniazid and rifampin for 7 additional months (total 9 months) 1, 5, 6
• Avoid pyrazinamide during pregnancy due to inadequate teratogenicity data 1, 6
• Never use streptomycin—it causes congenital deafness in approximately 1 in 6 exposed infants 1, 5, 6
• Add pyridoxine 25 mg daily to prevent peripheral neuropathy from isoniazid 7, 5
• Do not delay treatment based on pregnancy status, even in the first trimester—untreated TB poses greater risk to mother and fetus than medication exposure 1, 6

If Breastfeeding:

• Continue standard TB treatment while breastfeeding—anti-TB drugs in breast milk reach only 20% or less of therapeutic levels and do not cause infant toxicity 7, 8
• Provide pyridoxine 25 mg daily to the mother 7, 8
• The infant requires independent evaluation and treatment if exposed—breast milk drug levels are inadequate for prophylaxis or therapy 7, 8
• After 2 weeks of treatment, the mother is considered non-infectious and poses minimal transmission risk 8

Monitoring and Directly Observed Therapy

Implement directly observed therapy (DOT) for all patients to prevent treatment failure and drug resistance:

• DOT should be considered mandatory, as nonadherence is the major cause of drug-resistant TB and treatment failure 1
• Monthly clinical evaluations are required, including assessment for hepatotoxicity symptoms (jaundice, dark urine, abdominal pain, nausea) 1
• Baseline liver function tests (AST/ALT, bilirubin) are indicated for women who are pregnant, in the immediate postpartum period (within 3 months of delivery), HIV-infected, or have history of liver disease or regular alcohol use 1
• Obtain bacteriologic cultures before starting therapy and repeat throughout treatment to monitor response 2, 3

Role of Surgical Intervention

Consider oncoplastic surgery as adjuvant therapy if medical treatment fails or for diagnostic purposes:

• Anti-TB drug therapy remains the primary treatment for TB mastitis 9, 10
• Surgery may be necessary to obtain tissue for definitive diagnosis when clinical and radiologic findings are inconclusive 11, 12, 10
• One study showed 100% efficacy when oncoplastic surgery was combined with anti-TB drugs versus 92% with drugs alone, though this requires validation in clinical trials 9
• If surgery is planned, delay until after completing 2 months of anti-TB therapy to reduce post-operative complications by 50% 9

Critical Pitfalls to Avoid

• Do not mistake TB mastitis for breast cancer or pyogenic abscess—TB mastitis often mimics malignancy on clinical and imaging findings 11, 12, 10
• Do not use pyrazinamide in pregnant women—the teratogenicity risk is unknown and a 9-month regimen without it is preferred 1, 5, 6
• Do not assume breast milk provides adequate TB treatment for the infant—separate full-dose therapy must be prescribed if the infant requires treatment 7, 8
• Do not discontinue treatment prematurely—complete the full 6-9 month course even if symptoms resolve early 1, 2, 3
• Do not use streptomycin in women who are or may become pregnant due to irreversible fetal ototoxicity 1, 5, 6

Drug Resistance Considerations

If drug resistance is suspected or confirmed:

• Obtain drug susceptibility testing on all initial isolates 2, 3
• For isoniazid-resistant, rifampin-susceptible TB: use rifampin and pyrazinamide for 2 months, or rifampin alone for 4 months 1
• For multidrug-resistant TB (resistant to both isoniazid and rifampin): consult a TB expert and individualize treatment based on susceptibility patterns, typically using pyrazinamide plus ethambutol or a fluoroquinolone for 6-12 months 1, 2
• Change the regimen immediately if cultures remain positive and susceptibility testing shows resistance 2, 3