Background: Breast tuberculosis (breast TB) is an extremely rare disease, so case reviews are also rare.Methods: This study is a retrospective review of patients with breast TB who were treated between 2002 and 2012 at the Health Center of Gorgan City.Results: All 22 patients were females, their mean age was 32.4 years, and all were new cases. Patients presented with swelling of the breast (22%), lump (55%) and excretion from the involved breast (27%), and breast pain (55%). The highest rate of breast TB occurred in 2011 (27%). All patients received the DOTS regimen for a mean duration of 7.3 Â± 0.7 months; in addition, segmental resection was performed on 11 patients (50%).Conclusions: The findings confirmed that breast TB in Iran should be considered as a differential diagnosis of breast masses. All patients in our study received the daily and 'Directly Observed Treatment Short-course' (DOTS) regimens. Anti-tubercular therapy for six months with or without minimal surgical intervention currently is the main treatment. © 2014 Khodabakhshi and Mehravar; licensee BioMed Central Ltd

Khodabakhshi, B.

Mehravar, F.

BMC Women's Health

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Behnaz Khodabakhshi

Fatemeh Mehravar

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BMC Women s Health

Breast tuberculosis in Northeast Iran: review of 22 cases

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Golestan University of Medical Sciences Repository

Khodabakhshi and Mehravar BMC Women's Health 2014, 14:72http://www.biomedcentral.com/1472-6874/14/72RESEARCH ARTICLE Open AccessBreast tuberculosis in Northeast Iran: review of 22casesBehnaz Khodabakhshi1 and Fatemeh Mehravar2*AbstractBackground: Breast tuberculosis (breast TB) is an extremely rare disease, so case reviews are also rare.Methods: This study is a retrospective review of patients with breast TB who were treated between 2002 and 2012at the Health Center of Gorgan City.Results: All 22 patients were females, their mean age was 32.4 years, and all were new cases. Patients presentedwith swelling of the breast (22%), lump (55%) and excretion from the involved breast (27%), and breast pain (55%).The highest rate of breast TB occurred in 2011 (27%). All patients received the DOTS regimen for a mean durationof 7.3 ± 0.7 months; in addition, segmental resection was performed on 11 patients (50%).Conclusions: The findings confirmed that breast TB in Iran should be considered as a differential diagnosis ofbreast masses. All patients in our study received the daily and ‘Directly Observed Treatment Short-course’ (DOTS)regimens. Anti-tubercular therapy for six months with or without minimal surgical intervention currently is themain treatment.Keywords: Breast tuberculosis, Mammary tuberculosis, Tuberculosis treatment, IRANBackgroundThe World Health Organization (WHO) estimated thatthere were 8.7 million cases of tuberculosis (TB) in theworld in 2011, a rate of 125 cases per 100,000 people. Italso was estimated that there were 12 million prevalenttuberculosis cases [1]. Breast TB was first defined by SirAstley Cooper in 1829 as a rare form of extrapulmonaryTB [2]. Breast TB is a very rare disease [3-5] and consti-tutes only 0.025-1.04% of all breast diseases [6]. Itsprevalence has been estimated to be 0.1% of breast le-sions examined histologically, and it constitutes about3–4.5% of surgically-treated breast diseases in develop-ing countries [7]. Despite the high prevalence of tuber-culosis, mammary cells offer great resistance to thesurvival and multiplication of mycobacterium tubercu-losis [8]. The disease may be of primary etiology wheninfection affects only the breast, or it may result fromother foci in the body, which is termed as secondarybreast TB. Presentation of breast TB is variable and may* Correspondence: mehravar10261@yahoo.com2School of Public Health, Epidemiology and Biostatistics Department, TehranUniversity of Medical Sciences, 5TH Floor, Poorsina St, Keshavarz Ave, PostalBox: 14155–6446, Tehran, IranFull list of author information is available at the end of the article© 2014 Khodabakhshi and Mehravar; licenseeof the Creative Commons Attribution Licensedistribution, and reproduction in any mediumDomain Dedication waiver (http://creativecomarticle, unless otherwise stated.be confused with other disorders [9,10]. Fine Needle As-piration Cytology (FNAC) is the most extensively usedinitial invasive method for diagnosis of breast TB[11,12], and the ‘gold standard’ diagnostic tool for breastTB is bacteriological culture of breast tissue or theZiehl–Neelsen stain [10]. Breast TB is often misdiag-nosed as a pyogenic abscess or carcinoma of breast, bothclinically as well as radiologically, especially if well-defined clinical features are absent [13]. In the presentstudy, our aim was to evaluate demographic data, diag-nostic methods, and therapeutic regimens in 22 breastTB patients treated at the Tuberculosis Control HealthCenter in Gorgan, Iran over a period of 10 years.MethodsOver the 10-year period from 2002 through 2011, 22 pa-tients were diagnosed with breast TB, and the patientswere referred to health centers in Gorgan City for the‘Directly Observed Treatment Short-course’ (DOTS).Gorgan is in the center of Golestan state in northernIran, just southeast of the Caspian Sea. Demographicdata, such as age, gender, weight at diagnosis, ethnicity,location, occupation, marital status, educational status,BioMed Central Ltd. This is an Open Access article distributed under the terms(http://creativecommons.org/licenses/by/2.0), which permits unrestricted use,, provided the original work is properly credited. The Creative Commons Publicmons.org/publicdomain/zero/1.0/) applies to the data made available in thisKhodabakhshi and Mehravar BMC Women's Health 2014, 14:72 Page 2 of 4http://www.biomedcentral.com/1472-6874/14/72the family’s and the patient’s TB history, complaints, andphysical examination findings of the patient recordswere documented.The cytological findings of epithelioid cell granulomas,Langhans’ giant cells, and lymphohistiocytic aggregatesconfirmed the diagnosis. The discharge from the sinuswas subjected to Ziehl-Neelson staining and cultured foracid fast bacilli. Sonography was performed for 77.2% ofthe patients. Mammography was performed on threepatients (13.6%), and non-specific stromal coarseningexisted in all three patients. The chest radiographs of the22 patients were normal. The diagnosis of breast TB wasconfirmed by a combination of clinical suspicion and bi-opsy findings. After primary diagnosis of patients by ourdoctor, they were referred to a health center in Gorganand continued treatment as planned.In 1978, according to the World Health Organization’s(WHO’s) guideline [1], the Ministry of Health and MedicalEducation of Iran effectively implemented the DOTSstrategy to fight tuberculosis. Based on the national strat-egy of DOTS, new patients were treated with a short-termdiet for six months, followed by re-treatment with a regi-men of eight months. Both regimens consisted of twophases, i.e., attack and maintenance.The DOTS regimen was put into practice in Gorganin June 1998. The records of the breast TB cases thatwere treated between January 2002 and June 2012 werereviewed. The breast TB regimens used in the healthcenters in Gorgan City are presented in Table 1. In thisstudy, standard six-month anti-TB therapy (isoniazid, ri-fampicin, pyrazinamide, and ethambutol) was commencedwith good clinical response. The continuation phase lastedfour months with isoniazid and rifampin on a daily basisand the regime’s maintenance phase continued for an-other three months.Some patients had breast lumps that were potentiallymalignant, and they also underwent segmental mastec-tomy. Residual lumps after anti-tubercular therapy(ATT) may require surgical removal. Minimal surgicalintervention was required for drainage of abscesses ofthe breast or taking biopsies from the wall of the ab-scess, scraping of sinuses in the breast, and incisional orexcisional biopsy.Table 1 Breast TB treatment regimens [11]Treatment time Initial phase regimens Continuationphase regimens6 months 2 months of isoniazid,rifampycine, pyrazinamide,ethambutol or streptomycin4 months of isoniazidand rifampycine9 months 2 months of isoniazid,rifampycine, pyrazinamide,ethambutol or streptomycin7 months of Isoniazidand rifampycineThis study obtained ethics approval and was approvedby Ethical Committee of Golestan University of MedicalScience.Statistical analysisData relating to the duration of therapy and to whetherDOTS was administered were recorded with SPSS ver-sion 16.0. Descriptive analyses were performed to detectdifferences between subgroups.ResultsIn this study, 22 known breast TB cases were identified,and all the patients were female. The mean age of the pa-tients was 32.4 (range 23–66). All of the patients were newcases. Among the patients, 15 were of reproductive age,and one of the 15 was pregnant at the time of diagnosis.Patients presented with swelling of the breast (22%),lump (55%) and excretion from the involved breast (27%),and breast pain (55%). The left side of the breast was in-volved in 16 cases, and the right side of the breast wasinvolved in 4 cases. The disease was bilateral in two pa-tients. Most of the patients (59.09%) were from urbanareas, and most were of Persian ethnicity (68.18%), assummarized in Table 2. The highest rate of breast TB wasseen in 2011 (27%).Sonography was conducted for 17 patients, and a de-fined breast lump was found in 13 patients (55%); de-fined isolateral auxiliary lymph node involvement wasobserved in seven patients (31.8%); defined non-specificfindings were made in five patients (18.5%), includinghypoechoic masses, internal echoes, and irregular bor-ders; and bilateral auxiliary lymph node involvement wasobserved in one patient (3.7%). Mammography was per-formed on three patients (13.6%), and the results showednon-specific stromal coarsening in all three patients.The most frequently used diagnostic tool was excisionalbiopsy (81.81%) and positive TB culture (9.09%). Thebreast TB diagnostic criteria for this study were basedon biopsy and clinical response. Histopathology of thespecimen (lump) findings included epitheloid cell granu-lomas without caseous necrosis.Eleven patients underwent segmental mastectomyand anti-tuberculosis drug therapy, and another elevenpatients underwent just anti-tuberculosis drug therapyafter fine-needle aspiration. All patients completed ther-apy with a full recovery. Our treatment success rate was100%. A six-month treatment regimen was administeredto all patients, but for some patients (n = 4) that had afistula and abscess, the regime was nine months.Twenty-two patients received the DOTS regimen for amean duration of 7.3 ± 0.7 months; in addition, seg-mental resection was performed on 11 patients (50%),and two patients underwent complementary surgery fordrainage of abscesses.

Breast tuberculosis in Northeast Iran: Review of 22 cases

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Breast tuberculosis in Northeast Iran: Review of 22 cases

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