Breast tuberculosis (TB): diagnosis and treatment

TB of the breast is an uncommon disease that is often difficult to differentiate from cancer of the breast when it presents as a lump. 

TB is an infectious disease caused by a bacterium called Mycobacterium tuberculosis. It usually affects the lungs but can affect other parts of the body too. It is mainly spread by breathing in air-borne bacteria from people with active infectious TB disease.

Someone can be infected by the TB organism for years without getting sick or spreading the disease to others. However, if the immune system is weakened for any reason, this latent

TB infection can develop into an active disease. With the correct treatment, TB can be cured in most cases. Unfortunately, if it is left untreated it can be fatal.

Local statistics

In South Africa TB is endemic. This means that two thirds of the population is infected with TB, although most will not get the active disease. TB rates in South Africa are up to 60 times higher than in USA or Western Europe. In 2007, about 336 000 South Africans suffered from active TB and 112 000 of those died.  An important link to TB is the presence of HIV infections: more that half of all the TB patients are HIV positive.

TB of the breast

Breast TB is a rare form of TB. This is the case because it is generally accepted that breast tissue is not a fertile area for the TB bacteria to flourish. Reported cases of the condition are mainly from India and South Africa. However, with the global spread of HIV/Aids, this is changing. Reports are now emerging from other parts of the world as well. The most significant factor of Breast TB is that it can be confused with breast cancer.

How does it present itself?

TB of the breast is usually a disease of women aged between 20 – 50 yrs. The typical patient is a young woman with a breast abscess in the centre of the breast, or a firm, poorly defined irregular lump with associated skin or nipple retraction. It can initially be mistaken for breast cancer.

A pus-like discharge from the nipple is common. In advanced cases, tracts form from the breast tissue to the overlying skin, which can discharge blood or pus. These are called fistulae or sinuses. Ulcers on the skin can also occur.

The lumps are usually more painful than with breast cancer and the pain is usually dull and constant. Both the left and right breast are often infected.

How do you get breast TB?

Direct infection of the breast may occur through skin abrasions or through milk duct openings. Breastfeeding is known to increase the susceptibility of the breast to TB. During lactation the increased blood supply may facilitate infection and spread the bacteria. Therefore, the risk of contracting

TB is higher in when mothers are breastfeeding in poor hygiene conditions.

Another way of contracting TB in the breast is via blood or lymphatic vessels from sites elsewhere in the body. This is more likely to happen in immune compromised individuals.

Diagnosis

Radiological tests like a breast ultrasound and mammography are unreliable in making the distinction between Breast TB and Breast Cancer, because the changes are so non-specific. CT scans and MRI scans similarly, are of little use.

The most significant factor of breast TB is that it can be confused with breast cancer.

Diagnosis is best made with a full picture of the patient’s history and clinical examination and the non-specific mammogram or ultrasound findings. A fine needle aspiration can show changes consistent with tuberculosis. The accuracy of these tests is further improved by additional tests and stains looking for the bacteria or the DNA of the TB bacterium. (Ziel-Neilson staining showing Acid-fast bacilli or PCR respectively)

It is imperative to make the correct diagnosis. If an incorrect diagnosis of cancer is made, incorrect treatment is then instituted and major side effects can result with little hope of a cure. TB of the breast can be treated easily.

Treatment

Treatment of Breast TB with standard anti-TB drug therapy for six months usually results in good clinical response in uncomplicated situations. Surgery is only performed in patients showing a poor response to medication, or to drain TB abscesses, or to excise residual lumps after drug treatment. A mastectomy is reserved for cases with extensive disease with large, painful ulcerated lumps involving large parts of the breast.

MEET THE EXPERT

Dr Sumayya Ebrahim is a gynaecologist in private practice in Johannesburg. She is also a blogger. Check out her blog “vaginations by Dr E” on www.vaginations.co.za

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