Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Archana Dambal

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Dr. Archana Dambal
Department of General Medicine,
Belgaum Institute of Medical Sciences,Belgaum, Karnataka,INDIA,
On 30 Nov 2018




Dr Bhanu K Bhakhri

"The Journal of Clinical and Diagnostic Research (JCDR) has been in operation since almost a decade. It has contributed a huge number of peer reviewed articles, across a spectrum of medical disciplines, to the medical literature.
Its wide based indexing and open access publications attracts many authors as well as readers
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Faculty, Pediatric Medicine
Super Speciality Paediatric Hospital and Post Graduate Teaching Institute, Noida
On Sep 2018




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Professor & Head,
Department of Dematolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
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I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




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It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
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Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011

Important Notice

Original article / research
Year : 2011 | Month : December | Volume : 5 | Issue : 8 | Page : 1569 - 1573

Tubercular Mastitis is Common in Garhwal Region of Uttarakhand: Clinico athological Features of 14 Cases

Hatwal Deepa, Suri Vijay, Mishra Jai P., Joshi Chitra

1. MD Pathology, Assistant professor pathology VCSGGMS & R I, Srinagar Garhwal, Uttarakhand. 2. MD Pathology, Professor & head of department pathology VCSGGMS & R I, Srinagar Garhwal 3. MD Pathology & Microbiology. Associate professor pathology, VCSGGMS & R I, Srinagar Garhwal. 4. MS Obs & Gynae. Assistant Professor Obs & Gyne. V.C.S.G.G.M.S.& R.I. Srinagar Garhwal.

Correspondence Address :
Deepa Hatwal
Assistant professor pathology
VCGGMS & RI Uttrakhand
C/o Dr S.K. Hatwal, Health Care Centre
Upper Bazar, Srinagar Garhwal
Phone : 01346- 253501
E-mail: dhatwal@yahoo.com

Abstract

The incidence of breast tuberculosis is not uncommon but there is gross under reporting of such an important disease. It presents with mimics of breast abscess, fibrocystic disease and breast cancer. Breast tuberculosis has been rarely reported from Garhwal region of Uttrakhand. Breast tuberculosis has no well defined clinical features and apart from breast lump, vague complain of generalized weakness,maliase and low grade fever is non-specific presentation. Radiological imaging is not diagnostic. Diagnosis is based on the identification of cytological and histopathological findings of tubercular granuloma and identification of tubercle bacilli either under microscope or by culture. Anti-tubercular therapy for 6 months with minimal surgical intervention is the mainstay of treatment today. The risk factors include multiparity,malnutrition, lactation, trauma, past history of suppurative mastitis, immunocompromised state, drug abuse and emergence of AIDS. In this study we detected 14 cases of breast tuberculosis in 1 year duration that shows tuberculosis of breast is common in Garhwal region of Uttarakhand.

Keywords

Breast, tuberculosis, mastitis, granuloma,MGIT,Bactech,PCR

How to cite this article :

Hatwal Deepa, Suri Vijay, Mishra Jai P., Joshi Chitra. TUBERCULAR MASTITIS IS COMMON IN GARHWAL REGION OF UTTARAKHAND: CLINICO ATHOLOGICAL FEATURES OF 14 CASES. Journal of Clinical and Diagnostic Research [serial online] 2011 December [cited: 2019 Sep 16 ]; 5:1569-1573. Available from
http://www.jcdr.net/back_issues.asp?issn=0973-709x&year=2011&month=December&volume=5&issue=8&page=1569-1573&id=1790

INTRODUCTION
Breast tuberculosis is a relatively rare form of tuberculosis (1),(2) with an Incidence of less than 0.1% of all breast lesion in western countries and 4% of all breast lesion in TB endemic countries (3),(4). The first reported case was by Sir Astley coopers (1829).Reports has appeared in western literature. Secundder (1889,has reported 83 cases of Beast tuberculosis. 205 cases were reported by Shipley and Spender in 1926. Morgan (1931) collected 439 cases from literature.

Report from India has described the incidence from 3.0 to 5.38 % (Choudhary 1957; Dharkar et al 1968; Dube and Agarwal 1968; Pratap et al 1971; and Mittal et al 1977). Despite high prevalence of tuberculosis in India, only few hundred cases of tubercular mastitis are reported (5). Garhwal is an endemic area for tuberculosis but tubercular mastitis is rarely reported which is probably because of non-specific presentation and clinically difficult to diagnose (6). The incidence of tuberculosis is generally quite high in our country and so as the tuberculosis of breast may be frequent enough but possibly overlooked or misdiagnosed as carcinoma or pyogenic abscess or mistaken for other common lesion. Thus the onus of diagnosis is mainly upon pathologist. Sagar C Mhetre et al in their study found that breast tuberculosis is not an infrequent malady as presumed.

Tuberculosis of breast is most often seen in reproductive age group between 20–40 years females, rarely bilateral [3%], rarely seen in males [4%] and may coexist with carcinoma (7),(8),(9),(10). The risk factors include multiparity, malnutrition, lactation, trauma, past history of suppurative mastitis, immunocopromise state, drug abuse and emergence of AIDS (10). Breast lesion caused by atypical mycobacteria has been recently reported by Vertillie G et al (11). It presenta a diagnostic dilemma not only clinically, but also radiographically. Diagnosis is based on identification of characteristic cytological and histological features along with thepresence of tubercle bacilli under microscope or in culture or by PCR for Mycobacterium tuberculosis. Importance of cytology and histopathology in the diagnosis of tubercular mastitis is emphasized in this article. Demonstration of AFB in aspiration smear and histopathological smear stained with ZN for AFB is though a simple but effective way of diagnosis. This procedure along with PCR will be able to diagnose majority of tubercular Mastitis.MGIT ,Bactech culture for AFB as additional tools. The most commom mode of presentation is breast abscess with or without the involvement of axillary lymph nodes. The other presentation is hard lump mimicking carcinoma and sometimes an ill defined lump simulating fibrocystic disease. So here the responsibilities of pathologist is paramount in final diagnosis of tubercular mastitis. This study is presented with clinicopathological feature of 14 cases of tubercular mastitis, diagnosed in the Dept. of Pathology, V.C.S.G. Govt. Medical college, Srinagar Garhwal Uttarakhand, during one year period.

Material and Methods

All the patients with breast lesion referred to pathology department were subjected to fine needle aspiration cytology. Further confirmation was done either by demonstration of Acid fast bacilli or by histopathologically.PCR was done in cytologically highly suspicious cases with AFB negative on culture and where biopsy was not possible.

CLINICAL FEATURE
Out of 14 cases in 9 cases (64.3%) clinical diagnosis was breast abscess including sinuses in 2 and ulcer in 1. In 2 (14.3%) cases diagnosis was carcinoma breast and 3 cases (21.4%) was fibrocystic breast disease (Table/Fig 1). All cases were of married women with maximum number of cases occurring in between 26 -35 yrs (Table/Fig 2). Five patients were lactating (35.7%) at the time of diagnosis. Only one breast was found to be involved and was usually the right one. The diagnosis of tubercular mastitiswas suspected clinically in two cases. These cases presented with abscess and discharging sinus. Associated lympadenopathy was found in four cases (28.6%) on same side of which two were presenting along with carcinoma and two with breast abscess.

CYTOPATHOLOGIC FEATURE
Out of 9 cases of breast abscess ,acid fast bacilli on ZN staining were detected in 5 cases (55.5%). Remaining four cases of breast abscess in which cytologicaly degenerated granuloma was present, were subjected to culture by MGIT and Bactech and was found to be positive in 2 cases. AFB culture negative 2 cases were further subjected to PCR and were found positive.

In five other cases with clinical diagnosis of fibrocystic disease and carcinoma breast, microscopically there were evidence of epitheliod cells,langhans giant cells,mononuclear infiltration. But acid fast bacilli were not detected by microscopy in any of these patients. In these cases excisional biopsy was done for further confirmation.

HISTOPATHOLOGIC FEATURES
Lumpectomy were performed only in 5 patients of granulomatous mastitis, In which gross morphology showed firm to hard masses of varying sizes with nodulocaseous lesion in 3 cases and disseminated/ confluent tubercles in 2 case (Table/Fig 3). Microscopy showed caseating granulomas with epithelioid cells, both foreign body and Langhans giant cells and lymphomononuclear cells (Table/Fig 4) to (Table/Fig 5),(Table/Fig 6),(Table/Fig 7),(Table/Fig 8). Only in two cases acid fast bacilli could be demonstrated in biopsy which was negative in FNAC earlier (Table/Fig 9).

All these 14 cases was put on suitable anti-tubercular therapy and followed up for a mean period of six month, with isoniazid,rifampcin, pyrazinamide,and ethambutol for first two months, and were continued on isoniazid and rifampicin for next four months. Eight patients showed gradual recovery with decrease in erythrocyte sedimentation rate (ESR) and increase in body weight. In four patient clinical response was very slow so in these patient antitubercular therapy was extended for 12 month. One patient needed the addition of streptomycin and ofloxacin. One patient though was responding initially but later on could not come for follow up.

Discussion

Tuberculosis rarely involves the breast as breast tissue is remarkably resistant like skeletal muscle and spleen because it provides infertileenvironment for the survival and multiplication of bacilli (12),(13). The incidence is rising, which may be partly due to immunosuppression as well as emergence of resistant strains of Mycobacterium tuberculosis. We encountered here 14 cases of tubercular mastitis in one year seems too high as compared to other study which maybe because of the overall increase in the incidence of tuberculosis in India. In latest series Puneet et al (2005) reported 42 patients of breast tuberculosis out of 1016 in three year (14), Sagar C Mhetre et al (2011) reported 11 cases out 267 breast biopsy in 5 year study (15), Sunita singh et al (2011) in their case report found 3 cases of tubercular mastitis over a very short period of two months (16). The contributory factors are of poor socio-economic status, poor nutrition in women, lack of awareness ,environmental and geographical conditions of hill areas. Pratima Gupta et al (2005) also in their study found that there is rapidly rising trend of HIV infection from 1.19 % (1999) to 4.19 %(2005) in tubercular patients in hilly region in Uttarakhand (17).

Breast tuberculosis is either of primary aetiology or secondary to pulmonary tuberculosis (18). Mckeown and Wilkinson (18) suggested that breast may become infected by various ways as haematogenous and lymphatic spread, involvement from contiguous structure, direct inoculation and ductal infection are other mode of infection. The most accepted view for infection of breast tissue is centripetal lymphatic spread (13).Cooper’s theory stated that communication between axillary gland and breast results in breast involvement secondarily due to retrograde lymphatic spread (12). Spread from lung to breast was traced through tracheobranchial, paratracheal, mediastinal and intermammary nodes.

It usually affects the younger women between (20-40) years which are similar to the highest incidence of pulmonary tuberculosisreported in the same age group of female. It is extremely rare before the 10 year [6,7,9]. In Indian literature most of the cases reported were in this age group; Chaudhari 85% (19), Dharkar et al 100 % (20), Dubey and Agarwal 70 % (21). All our cases were young except 2 (85.7%).This may be because the female breast undergoes frequent changes during period of lactation and pregnancy and is more vascular and liable to trauma and infection (13). 5 of our cases (35.7%) presented during lactation.

Both breasts are reported to be involved with equal frequency. Bilateral involvement is relatively rare and present only in 3% cases (9). None of our cases had bilateral involvement.

Abscess is one of the common mode of presentation of breast tuberculosis especially in young women (8). In our study nine cases (64.3%) presented as abscess. In some studies lump was the common presentation in breast tuberculosis (22). In our series 5 cases(35.7% ) out of 14 presented as lump .The common location of lump in breast tuberculosis is upper outer quadrant as in carcinoma breast (7). Multiple lumps are less frequent (22). Tubercular lumps are irregular, ill-defined, hard similar to that seen in carcinoma (6), (23). Nipple retraction and peaud’orange with extensive axillary nodal tuberculosis can also be seen in breast tuberculosis. All our cases were clinically diagnosed as either inflammatory breast abscess or benign or malignant breast lesion. In our reports 4 cases (28.6 %) of axillary lymph nodes were enlarged.

Relevant investigations in our cases showed raised ESR in all (100)% cases and healed lesions in lungs in 3 cases.

The definite diagnosis of breast tuberculosis is made by isolation of the tubercle bacilli in cytological and histological material of breast tissue by Ziehl-Neelsen (ZN) stain or culture or highly sensitive PCR (Polymerase Chain Reaction) tests. In our cases Acid fast bacilli in ZN staining were observed in 5 case on cytology and 2 cases on histology that is (50%) of all cases. A variety of PCR techniques have been developed for detection of specific protein sequences of Mycobacterium tuberculosis and other mycobacteria. However, PCR has got some limitations like it is negative in paucibacillary specimens. Positivity rates of PCR are ranging from 40-90% in diagnosing tubercular lymphadenitis. PCR is not much used in the diagnosis of tubercular mastitis. It is used mostly as a diagnostic tool to distinguish tubercular mastitis from other granulomatous mastitis in selected cases (24),(25). A negative PCR result does not exclude TB with certainty.

Mycobacterium culture is considered as the gold standard for diagnosis of tuberculosis but important limitation are the time required and negative result in paucibacillary specimen (1). Important time saving and sensitive techniques are Bactech, MGIT (Micobacterium growth indicator tube), Septichek, MB/BacT system (23). Most of these new techniques are very expensive and sophisticated to be of any practical benefit to the vast majority of tuberculosis patients living in remote area so not routinely recommended but it can be discretely used in tertiary hospital like ours . In our cases we performed AFB culture in 4 cases using LJ, Bactech and MGIT media and found positive result in 2 cases and negative in 2 cases. The cases with negative culture were found to be positive by PCR technique.

FNAC is proving very useful in diagnosis of breast lumps with or without nodes. The presence of epitheliod cell granulomas and caseous necrosis is diagnostic of tuberculosis of breast only in 73% cases (2). Absence of demonstration of necrosis on FNAC does not exclude tuberculosis in view of small quantity of the sample examined. Thus in cases which only demonstrate epitheliod cell granulomas on smears that are negative for AFB, a diagnosis of granulomatous inflammation, possibly tuberculosis should be made. In breast abscess like picture dominated by acute inflammatory exudates, AFB positivity or histological confirmation is mandatory to call the lesion as tubercular (12),(26). We found that FNAC of enlarged lymph nodes in four cases showed granulomatous lymphadenitis but AFB was negative in 2 cases.

Mallika and Shukla in 2004 classified breast tuberculosis into three pathological varieties i.e. nodulocaseous, Disseminated/confluent and tubercular breast abscess. In our study we detected 14 cases of tubercular mastitis based on cytological featurs,histopathological features and demonstration of tubercular bacilli. Out of 14 cases, 9 cases were of tubercular breast abscess,3cases were of nodulacaseous histological type and 2 cases were having confluent tubercular granuloma on histopathological examination.

Histologically tuberculosis causes both non-caseating and caseating granulomatous granulomas. It has to be differentiated from other granulomatous breast disease. Most important differential diagnosis is granulomatous lobular mastitis described in 1972 by Kessler and Wolloch, where granulomas, leucocytes infiltration and abscesses are confined to the breast lobules, but neither caseation nor organisms are found (27), (28). The other causes of granulomatous mastitis are sarcoidosis, plasma cell mastitis, mycosis mastitis,parasitic mastitis, fat necrosis and indigenous granulomas due to rupture of milk cyst where sometimes the microscopical picture is indistinguishable from that of tuberculosis (29),(30).

The number of reported cases seems to higher than what is reported in medical literature. But significant factors which are responsible for high incidence rate are (1) host related factors such as presence of anemia, malnutrition, low general condition of women of reproductive age group. (2) High quality technichues such as Bactech, MGIT, and PCR employed in this study. (3) High degree of suspicion of tubercular mastitis in all cases presenting as breast abscess. All these three causes contributed in detection of tubercular mastitis.

Conclusion

This report highlights that breast tuberculosis is not that all rare as being presented. Abscess and lump is common presentation. Meticulous attention to histology of cells and acid fast bacilli should be paid. In addition modern diagnostic tools as modern culture technique and PCR must sought in suspicious cases so that many cases of so called pyogenic breast abscess will turn out to be of tubercular in origin which may or may not have superadded bacterial infection .The disease is essentially curable with modern anti-tubercular chemotherapeutic drugs with surgery playing a role in the background only .

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