BREAST TUBERCULOSIS SIMULATING MALIGNANT TUMOR: A CASE REPORT

Breast tuberculosisis an infection that affects youngwomen in theirgenitally active period. It isoftenprimary and creates issues in and Treatmentisactuallybased on The prognosisis favorable undertreatment. We have to in to the medicalliteraturewritten the

The examination at admission found the patient in good health condition, no fever, heart rate at 71 beats/minute,blood pressure at 125/68 mmHg.
On the physical exam, breasts had an average size. Palpation of the right breast found induration in the upperexternal quadrant that was painless, mobile, measuring 6 cm from the major axis. The examination of the other breast was normal. There were no lymph nodes. Histopathologicalexamination of the micro-biopsywas in favor of granulomatousepithelial-gigantocellularmastitiswithoutcaseousnecrosis, whichcanberelatedwithtuberculosis.
Thebacteriologicalanalysis of biopsyshowed an important cellular reactionalongwithsterile culture. The Quantiferon-TB came up positive, confirming a MycobacteriumTuberculosis infection. Prior to that the Lowenstein-Jensen culture turned out to be positive.
Based ontheseclinical and paraclinicalelements, the diagnosis of breasttuberculosiswasmade and the patient wasputedunder anti-tuberculosisantibiotics for 6 monthsfollowing the protocol ofMoroccan national tuberculosis program. Treatmentwaswelltolerated.

Epidemiology:
Mammary tuberculosis is an extremely rare pathology. It represents between 0,06 and 1% of all localizations of tuberculosis, and 0,5 to 4,5% of breast pathologies. Its low frequency could be explained by the nature of the mammary tissue, not propitious enough for the proliferation of the tubercular bacilli.
Since the first case of breast tuberculosis described by Astely Cooper in 1829 as a cold breast tumor, so far about 900 cases have been reported [1]. Breast tuberculosis is mostly encountered in tuberculosis-endemic countries. Asia has the largest percentage with 45,2% of reported cases, followed by 27,5% in Black Africa, 17,2% in North Africa, 16,2% in Europe and 4% in America [2]. ZEKRI and al. reported that in Morocco during the past 8 years, the incidence of breast tuberculosis represents 0.4% of all mammary affections compiled in the department of gynecology obstetrics "A" inIbnRochdUniversity Hospital in Casablanca, which is quite similar to those published by studies done in North Africa [3].
Breast tuberculosis affects 95% of woman in their genitally active period from 20 to 50 years old. The risk factors are multiparity, breast-feeding, traumatic breast injuries, chronic mastitis and AIDS [4]. We shall add that 21 cases were seen among men [5].

Transmission Routes:
Breast Tuberculosis is considered primary in the absence of any other localization, which is the most frequent case. In this situation, the transmission is direct, consequently to an abrasion of skin or the galactophorous ducts. It is 162 considered secondary if the infection has started in another localization. The breast is often contaminated by contiguity through lymph nodes, intra-thoracic, cervical, supraclavicular or axillary ones, or from other neighboring foci. It spreads more rarely by hematogenous route [1][2][3][4].
In 50 to 75% of mammary tuberculosis, axillary nodes are involved, but they could be cervical or mediastinalas well. It spreads by antegrade or retrograde extensions through the lymphatic vessels from intra-thoracic or intraabdominal tuberculous localizations. The contiguity involves pleural, costal, or sternal lesions. The blood hematogenous spread is rare, described in the case of military tuberculous [6-7-8].

Clinical Diagnosis:
Mammarytuberculosispresents a wide range of clinicalfeatures. It has almostalways an insidiousonset. It israrely acute. The lesions are oftenunilateral and mainlyat the level of the upperouter quadrant. According to Wilson and MacGregor, bilaterality has only beenobserved in 3% of cases [9].Amongyoungwomen, mammarytuberculosismimics a pyogenicabscess, in the elderly, It mimicsmammarycarcinoma [10]. In our case, itwassuspicious of malignancy in MRI.
However, someclinicalcriteriasmightbeuseful to draw attention to the etiology of tuberculosis: The existence of a recurrentbreastabscessinspite of antibiotictherapy and propersurgical drainage on previous occasions.

Four forms are usuallyencountered:
The nodularform:with the presence of a hard lump, poorlydefined (craggy, withirregularmargins/edges) and poorlymobile, painless, accompanied or not by axillarylymphnodes, evoking a malignanttumor. This is the case of our patient.
The scleroticform: itisrather the case of the elderlywith the presence of apainful mass and indurationthatrarelyevolvestowards suppuration.
In other cases, Cervical, supraclavicular, or contralateralaxillarylymphnodesmayalsobeobserved. An abnormallymphnodemayprecedeany affection of the mammary gland and thereforeconstitute the onlyreason for consultation [7].
An oval area withundefined contours with skin retraction suggestive of malignancy. Stellar dense opacitywith skin retraction and thickening.
Thick, irregularmarginswith an abnormal architecture and a micronodularlesions of the breast. It's oftenassociatedwith significant skin thickening and the aspect of military breasttuberculosis.
Apartfromclinical manifestations (which are the recurrentabscesseswith multiple fistulous orifices), TABAR identifiedthree radio-clinicalforms : A nodularform:that corresponds to a painlesstumor mass of very slow growth, producing a dense round or 163 ovalshapewithblurredmargins. The case of our patient.
A diffuse form:caracterized by an inflammatory, painfultumor mass withulceratedskin and nippledischarge. The mammographicpresents a dense mass with a skin thickening in relation to the lesion.
A sclerosingform: pseudo-neoplasticlesionswith a predominantfibrosis. It results in a higherdensity and homogeneity of the mammary gland: an increase in opacitywithglandularretraction, whichmightbeaccompaniedwith architectural distortion.
In the Histopathologicalexamination, mammarytuberculosisappears in the form of a reddish or grayishyellowishlesion, sometimesalongwithulceration areas suggestive of neoplasticlesion. The lump size is variable. The consistencyisinitiallyfirm, thenbecomes soft in the case of caseum.
The histological section shows a lump strewnwithwhitish granulations or necroticat the center, resulting in a yellowishgranular pus.
Two classifications are used for mammarytuberculosis: 8. The

DifferentialDiagnosis:
A number of diagnoses must beexcludedbeforewemakethe diagnosis of breasttuberculosisincludingbreast cancer, whichshouldbe the first concern of all physiciansbecause of itshighfrequency.It is important to note thatin themedicalliterature,formsassociating cancer and mammarytuberculosis have been reported, hence the need for the histopathologicalstudy of the mammary tissue in order to eliminate an associatedcarcinoma.

Treatment:
Itisidentical to that of the other extra-pulmonarytuberculosis sites according to the National Tuberculosis Control Program. Itconsists of an intensive phase combiningIsoniazid, Rifampicin and Pyrazinamide for 2 months, followed by a consolidation phase ivolvingIsoniazid and Rifampicinfor 4 months: 2RHZ / 4RH. Antituberculouschemotherapyiscontrolled and administeredprimarily as an out-patient-treatment.
The indication of surgeryislimited. It remainsnecessary for diagnosis (throughbiopsy) however as a therapeuticmean, itisrecommendedespecially in second intention if therewas a badresponse to medicaltreatment. Surgerywouldinvolve the lump excision or drainage ofabscess, by resecting as much as possible the necrotic and infected tissues, or by a segmentectomy (quadrantectomy) or total mastectomy, if the breastiscompletelyravaged and riddledwithfistulas.

Prognosis:
The life threat for the patient whenmammarytuberculosisisisolated.Meaning, the vital prognosisdepends on the othertuberculouslocalizationswhich must besystematicallyinvestigatedwith the utmost attention. These extramammarylocalizationsmightbe progressive or quiescent [1]. 166

Conclusion:-
Breasttuberculosisis rare even in endemic countries. However, itdeserves to bestudied due to itsextremeresemblances to breast cancer. It affects mainlyyoungwomenduringtheirgenitally active periods. It ispromotedby:multiparity, pregnancy, lactation and immuno-suppression, especially HIV infection.
Radiological and clinical exam don'trevealanyspecificsigns, hence the need for a bacteriologicalstudy and histologicalexamination to ensure and confirm the diagnosis.
The treatmentismainlymedical. However, surgicaltreatmentisuseful in case of doubt or after the failure of medicaltreatment. The outcomeundertreatmentisgenerally favorable.
Improving the prognosis of mammarytuberculosisinvolves an earlydiagnosis and physician insight.
Weshall stress on the importance and the crucial need to promote the preventivemeansprevention in order to eradicatethisdisease.