A 77-year-old man presented with depressive mood, asthenia, anorexia and weight loss of 20 kg. He also had a 1-month history of an enlarging and non-painful breast lump (Fig. 1). He did not have fever, night sweats, cough or breathlessness. He denied trauma or contact with tuberculosis. Physical examination revealed a firm and elastic mass in the internal quadrants of the left breast with well-defined contours, about 6 cm in diameter. Local temperature was normal and the overlying skin and nipple were intact. There was no evident neck or axillary palpable adenopathy. Laboratory tests showed a white blood cell count within normal limits, haemoglobin of 12.1 g/dl and C-reactive protein of 5.42 mg/dl; all other blood chemistry results were within normal limits. Radiography showed no obvious lesions (Fig. 2). Mammary ultrasound revealed in the inner quadrants of the left breast a thick-walled cystic formation measuring 69x20 mm, with detritus in the region of greatest slope. Fine needle aspiration cytology (FNAC) of a white fluid revealed a necrotic background with granulomas without neoplastic cells. Polymerase chain reaction (PCR) and acid-fast bacilli stain of the aspirate were both positive for tuberculosis. Computed tomography (CT) of the thorax showed a liquid collection in the left anterior thoracic wall, measuring 31x80 mm, associated with irregularity and discontinuity of the 4th left costal cartilage, with a fistulous tract that crossed the cartilage into a small locus posterior to the left internal mammary artery; in the upper left lobe there was a cavitated nodule measuring 22 mm, compatible with an active tuberculous process (Figs. 3 and 4). Positron emission tomography (PET) showed a possible nodule in the left upper lobe and bilateral mediastinum-hilar adenopathy, with increased uptake of FDG-F18 (Fig. 5).
Peripheral uptake of FDG-F18 was noted as well in a hypodense mass in the left anterior thoracic wall. An interferon-gamma release assay (IGRA) was positive and HIV serology was negative. A sputum smear was positive for acid-fast bacilli (AFB) which was also positive by Ziehl-Neelsen staining. Sputum culture was positive for Mycobacterium tuberculosis complex that was sensitive to all tested drugs. The final diagnosis was pulmonary tuberculosis (PT) with a tuberculous mass in the left anterior chest wall, as a result of direct extension from underlying pleural and pulmonary disease.
Quadruple therapy with anti-tuberculosis drugs was started: isoniazid (300 mg), rifampicin (450 mg), ethambutol (800 mg) and pyrazinamide (1500 mg). The mass did not improve with medical treatment and so was drained. The patient was discharged home following 26 days in hospital after he had improved clinically, gained weight, and three sputum smears were negative.
Computed tomography (CT) of the thorax showing pulmonary tuberculosis lesions.