CASE PRESENTATION
A 34-year-old woman presented to our hospital, Clinical Hospital of the President Association and the Government of the Kyrgyz Republic, Bishkek, with complaints of a unilateral right painless breast lump of 2 months’ duration. The initially painless lump became painful with induration of the skin, ulcer formation, and purulent discharge (pus) from the sinus on the right breast for 20 days before hospitalization. She denied a history of weight loss, night sweats, loss of appetite, and respiratory symptoms. There was no family history of breast cancer, tuberculosis, or other pulmonary diseases. The systemic examination was normal.
Local examination of the right breast revealed a 1.0-cm sinus in the upper outer quadrant with a 2×2-cm palpable lump, and purulent discharge was noted. There were no clinical manifestations or abnormalities in the left breast or nipple-areolar area and no signs of nipple discharge.
Except for the elevated erythrocyte sedimentation rate (102 mm/h), her laboratory panel was within normal limits. The patient underwent computed tomography of the neck, abdomen, and breast, which showed a 2×2-cm lump in the right breast. Unilateral axillary lymphadenopathy was noted on the right side with multiple nodes ranging from 10 to 20 mm in size. Further evaluation of the right breast with ultrasound examination revealed a hypoechoic lesion with heterogeneous formation (87×17 mm) with elongated and irregular borders. Doppler ultrasonography (US) revealed elevated circumferential vessels in the central avascular lesions as a sign of existing infection, and a diagnosis of breast abscess was made.9 However, there was no symptom alleviation even after a week of co-amoxiclav (1000 mg) every 12 h.
For a definitive diagnosis, the patient underwent FNAC of the right breast lump. Touch imprint smears prepared from the pus revealed acid-fast bacilli (AFB) on Ziehl–Neelsen (ZN) staining. Histological study of tissue pieces revealed the presence of Langhans giant cells, epithelioid cell granulomas, caseous necrosis, lymphocytes, necrotic foci, and fibroblast clusters. Mycobacterium tuberculosis complex was confirmed by a cartridge-based nucleic acid amplification test sensitive to rifampicin in the FNAC sample.
Excision of the fibrous tract and resection of the rib with pus and necrotized tissue were performed. The patient was started on standard antitubercular therapy (ATT) with 2-month regimen (isoniazid, rifampicin, pyrazinamide, and ethambutol), followed by 4-month regimen (isoniazid and rifampicin). She consistently visited the hospital for follow-up for 1 year, and no disease recurrence was noted.