We report a case of breast tuberculosis that was treated in the Breast Unit of our hospital. A 26 year-old Eritrean female with a personal history of HIV infection and familiar history of breast cancer (her sister had died at the age of 34) came to our Emergency Department showing generalized limphoadenopathy and weakness in addition to a huge right breast mass. The patient was subjected to a CT scan of neck, abdomen and chest, that revealed a big mass in the right breast of about 10 x 7 cm, bilateral latercervical colliquated lymph nodes, the biggest being 27 x 20 mm, many right ascellary and retropectoal lymph nodes, and paraaortic, celiac and paracavale lymph nodes, but no nodes in the chest and no pleural effusion. For this reason she was hospitalized in Medicine Department with a suspicious diagnosis of lymfoma. During the stay, she underwent a mammography (Fig. 1) which showed a generalized increased radioopacity spread throughout the right breast.
Ultrasound scan was apparently useful for characterising the ill-defined breast mass and excluding the presence of solid masses. But the findings of a hypoechoic lesion with heterogeneous internal echoes and irregular borders were not specific ones. The Color Doppler showed increased circumferential vascularization in avascular centered lesions which might be interpreted as a sign of continuity of the infective process. For this reason it was diagnosed a breast abscess.
While being treated with antinflammatory drugs and a aspecific antibiotica therapy, the patient came up to our Breast Surgery Unit Department because she had not had any improvement of symptoms.
Our examination revealed a tender mass measuring 12 x 10 cm that involved all right breast. Her skin was not erythematous and local temperature was normal. She was painless. The mass was soft in consistency, floating and mobile on the chest wall and there were no signs of inflammation. It meant the possible presence of a "cold abscess" or a big cystis. Moreover, there was a clinically palpable right axillary lymphadenopathy.
The total leukocyte count and erythrocyte sedimentation rate were low; the other blood tests were normal except for the electrophoretic protidogram where we found a high level of gamma globuline.
Fine needle aspiration (FNA) showed a milky and greenish shaded fluid. On needle aspiration, some thick pus came out and it was drained out of about 200 ml. The pus was sent for bacteriological, citological and coltural test, the results of which were negative for aerobic, anaerobic bacteria and fungi.
The patient had a latercervical lymph node core biopsy that exluded lymphoma. The evaluation of the specimen revealed only inflammatory cells, including neutrophils, lymphocytes, and abundant macrophages, granulomas with central caseaous necrosis and epitheloid histiocytes. But by means of nucleic acid probes and PCR, it was possibile to identify the Mycobacterium tuberculosis. The laterocervical limph node was due to a scrofulous swelling.
The patient was put on anti-tubercular drugs treatment (rifampicin 600 mg, isoniazid 300 mg, pyrazinamide 1500 mg and ethambutol 1000 mg per day) for 2 months which continued with the addition of rifampicin and isoniazid therapy for 4 additional months. In the follow-up period of 6 months, the patient recovered very well and was advised to continue the treatment.
At the end of the antituberculous treatment period, the patient appeared to be clinically and radiologically without any evidence of residual disease.