Background

Tuberculosis has been gaining renewed interest for several years, mainly because of the resurgence of extrapulmonary forms in western and tropical countries, and in the Maghreb. This could be explained by the increasing of the prevalence of HIV infection, the emergence of strains of mycobacteria that are resistant to usual treatments, the immigration of populations from high rate of tuberculosis and the release of anti-tuberculosis campaigns (Ben et al., 2005).

The elective extrapulmonary localizations are, in order of decreasing frequency: the ganglia, the peritoneum, the pericardium, the kidneys, the skin, the joints, the meninges and the bone (Elmrabet et al., 2002; Ben et al., 2005).

Breast localization is very rare, accounting for less than 0.1% of cases. Nearly 900 cases have been reported in the world literature (Luh et al., 2007; Fadaei-Araghi et al., 2008). This location can be primitive or secondary to locoregional tuberculosis or disseminated, and it often poses diagnostic difficulties both clinically and paraclinically (Ben et al., 2005; Fadaei-Araghi, et al., 2008).

1 Observation

Mrs.G.N, 68 years old, multiparous, with no particular antecedents, in particular no concept of tuberculous contagion, who presented herself to our service for mastodynia appeared since two months. The clinical examination found a right inflammatory breast (Figure 1; Figure 2) with presence of homolateral axillary lymphadenopathies suggestive of breast cancer progressively advanced. The left breast was without abnormality the rest of the clinical examination also.

Figure 1 profile view of the right breast

Figure 2 inflammatory aspect of the right breast

Mammography (Figure 3) showed an increase in right breast density with diffuse thickening of the soft tissues without nodular lesions or micro calcifications. Breast ultrasound revealed diffuse cutaneous thickening with an infiltrated aspect of the mammary tissues, especially in retro-areolar, associated with multiple hypoechogenic axillary lymphadenopathies, the largest of which was 32 mm x 16 mm. The lesion was classified as ACR 4. A cutaneous biopsy and a biopsy with the axillary lymphadenopathy were carried out the anatomopathological examination objectified non-specific chronic fibro-inflammatory changes of the skin, and the presence of epithelio-giganto-cellular granuloma with caseous necrosis for the biopsy axillary lymphadenopathy. The diagnosis of tuberculous mastitis with associated ganglionic invasion was retained. The patient received antituberculous treatment with good clinical progression.

Figure 3 Mammography showed an increase in right breast density with diffuse thickening of the soft tissues without nodular lesions or microcalcifications

2 Discussions

Breast tuberculosis is a very rare form of tuberculosis. Its frequency varies from 0.06% to 0.1% of tuberculosis (Khanna et al., 2002; Agoda-Koussema et al., 2014). The rarity of this clinical form could be explained by the fact that breast tissue does not seem to be very conducive to the survival and multiplication of tubercle bacilli (Marinopoulos et al., 2012).

It essentially affects the young woman (Boukadoum et al., 2012). Pregnancy, lactation and multiparity are risk factors (Hawilo et al., 2012), which are explained by the effect of galactophoric ectasia during lactation.

Routes of infection are diverse (Khanna et al., 2002): the lymphatic route or axillary lymphadenopathy is often found; hematogenous pathway, in the context of a miliary tuberculosis; propagation by contiguity from a neighborhood focus; The ductal: dilation of the galactophoric ducts in women during pregnancy or lactation increases the sensitivity of these ducts to infection with bacilli; The direct way: exceptional, it is the penetration of the bacillus of Koch in the breast following a cutaneous abrasion or galactophoric.

Classically, there are two types of breast tuberculosis: secondary with involvement of other organs and primary or tuberculosis appears strictly localized in the breast, the latter is the most common (Marinopoulos et al., 2012; Gulpinar et al., 2013).

Concerning our patient the attack was primitive.

The attack is often unilateral and sits mainly at the level of the upper quadrant of the breast bilateral would be observed in only 3% of cases.

Clinically, mammary tuberculosis is characterized by the absence of specific clinical signs (Hawilo et al., 2012), whether in the form of a nodular mass or an inflammatory mass mimicking breast cancer. General signs of tuberculous impregnation (asthenia, anorexia, weight loss and vesperal fever) are classically present, but may be absent or incomplete.

However, there are clinical criteria that can lead to tuberculosis (Khanna et al., 2002): the existence of recurrent abscess rebelling to antibiotics; the existence of fistulized axillary lymphadenopathy, mammary fistula with nipple discharge and the existence of a breast fistula with intermittent flow rhythmized by the menstrual cycle.

On the radiological level, there are no specific mammographic signs of mammary tuberculosis (Morsad et al., 2000; Filippou et al., 2003), mammography may show irregular heterogeneous opacities, poorly limited sometimes with calcifications rather orienting towards a malignant etiology. On ultrasound, mammary tuberculosis often appears as a hypoechoic, heterogeneous image well or poorly limited with minimal posterior reinforcement (Filippou et al., 2003). On MRI, the aspects are not specific because they are found in carcinomas and abscesses. However the MRI makes it possible to make the assessment of locoregional extension.

The intra dermal reaction to tuberculin is usually positive in the endemic area. This test is insensitive, and may give false negatives, not excluding the diagnosis of tuberculosis (Daali et al., 2001).

The diagnosis of certainty is histological examination (Mirsaeidi et al., 2007) with the detection of epitheloid and giant cell granuloma with caseous necrosis.

The diagnosis of certainty can be as bacteriological and is based on the identification of Mycobacterium tuberculosis in the biopsy or in the secretions of breast fistula. However, the tubercle bacillus is not found only in 25% of cases (Makanjuola et al., 1996). In addition, culture it takes four to six weeks.

The main differential diagnosis to be feared in breast tuberculosis is breast cancer. Other pathologies are to be discussed, such as breast abscess, fibroadenoma, sarcoidosis and granulomatous mastitis.

In our observation, in front of an inflammatory breast in an elderly and menopausal woman, the first diagnosis to evoke is essentially breast cancer and only the histological examination which allowed making the diagnosis of mammary tuberculosis.

Therapeutic management of breast tuberculosis is usually based on conventional quadruple therapy with isoniazid, rifampicin, ethambutol and pyrazinamide for two months, followed by isoniazid and rifampicin for a total duration of nine to twelve months.

The surgical act is primarily a means of diagnosis by performing biopsies, excisions or lumpectomies to obtain histological certainty (Elmrabet et al., 2002; Ben et al., 2005; Luh et al., 2007). In the case of resistance to treatment antituberculosis or locally advanced diseases, a mastectomy can be offered for therapeutic purposes (Romero et al., 2000; Elmrabet et al., 2002; Ben et al., 2005; Harris et al., 2006; Luh et al., 2007). Currently, some authors advocate percutaneous drainage of abscess under tomographic or ultrasound control.

Once the treatment is done, the prognosis is excellent, subject to appropriate care of others tuberculous localizations (Jalali et al., 2005). However, rigorous monitoring of adherence to treatment is necessary to prevent recurrence and the development of resistance to anti-tuberculosis drugs. Finally, the risk of contamination of the breastfeeding child deserves special attention, and can be discussed weaning.

3 Conclusions

Breast tuberculosis is a very rare localization of the tuberculosis. In tuberculosis endemic countries, this diagnosis should not be ignored and should be mentioned in the light of certain clinical and radiological data.

Breast cancer remains the main differential diagnosis to be eliminated. The medical and surgical management allows a favorable evolution in the majority of the cases.

Authors’ contributions

R.H: Editing and supervision,read and approved the final manuscript. D.A: participated in the drafting of the observation, read and approved the final manuscript. B.N: participated in the drafting of the discussion, read and approved the final manuscript. A.A: checking references. All authors read and approved the final manuscript.

Acknowledgments

We thank the anatomopathology department of Ibn El Jazzar Hospital, Kairouan.

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