A 64-year-old female presented to her primary care physician with a tender right breast lump that had been present for 4-5 days. Additionally, she had been feeling feverish and fatigued. Further history indicated that she recently moved to the United States from Bangladesh. Her primary care physician proceeded to perform an ultrasound needle guided biopsy. Biopsy showed abscess formation and necrotizing granulomatous inflammation. Ziehl-Neelsen and Gram stains were negative for any organisms. Patient diagnosed with an abscess and prescribed a course of oral antibiotics. Several weeks later, cultures from the site grew tuberculosis. The patient was travelling abroad at this time and was unable to follow-up. Upon returning to the United States, the patient was informed of the diagnosis of tuberculosis but was unable to obtain an appointment with an infectious disease specialist in her city of residence. A couple months later the patient presented to our infectious disease clinic complaining of daily fevers and a nonhealing lesion on her right breast. She was not complaining of any other symptoms at that time.
Physical exam revealed that she was afebrile but tachycardic. Breast exam was significant for a 1-inch movable mass on the right anterior axillary line without overlying skin changes, warmth, erythema, or nipple changes. Physical exam was otherwise unremarkable. The patient was prescribed oral antituberculosis therapy and was counseled on the need for her family members to be tested for tuberculosis as well. However, the patient's condition worsened over the next couple days and required admission to the hospital. During her hospital admission, her creatinine was found to be elevated from her baseline and she was started on IV fluids. A chest X-ray was obtained and did not reveal any cavitary lesions. A CT scan of the chest revealed nonspecific enlarged axillary, mediastinal, and breast lymph nodes; evidence of prior granulomatous disease of the lungs; no evidence of consolidation, pleural effusion, or pneumothorax; and a diffusely enlarged thyroid with multiple nodules. We were unable to obtain sputum cultures during this admission as the patient was vomiting.
The patient was started on oral pyrazinamide, isoniazid, and rifampin in the hospital. Over the course of three days, the patient showed marked improvement in her symptoms and was discharged on antituberculosis therapy.