1. BREAST LUMP: A rare presentation of Tuberculosis
“THE GREAT MASQUERADE”
CASE REPORT  A 19 yr old girl comes with history of pain and lump in the left breast since 20 days. Also gives history of on and off fever since 2 months. There was a significant family history of tuberculosis. Her brother had pulmonary tuberculosis 2 yrs back and has completed treatment. She was pale, poorly built and malnourished.
INVESTIGATIONS
INTRODUCTION
Tuberculosis presenting as breast lump is a rare form of tuberculosis. It can be divided into primary and secondary form. Primary form is rare. Breast tuberculosis is a rare disease, with an incidence of 3–4% in tuberculosis endemic regions, such as India and Africa. The clinical signs of mammary tuberculosis can be insidious and nonspecific and often simulate signs of breast carcinoma or can present as acute abscess.
DISCUSSION 
Breast tuberculosis is a rare form of extra pulmonary tuberculosis.
The most common symptom is a lump in the breast and also presents with multiple sinuses, ulcers, matted nodes.
Pain in the lesion is present more frequently, than a carcinoma but less than abscess, often being a dull constant, nondescript ache with dull throbbing type in our case.
Primary manifestation of TB is mostly seen in premenopausal age.
Fine-needle aspiration cytology can be diagnostic in about three-fourth of patients with appearance of epitheloid granuloma and necrosis or langhan's giant cells.
Our patient did not have any focus of tuberculosis outside the breast, both on physical and radiological examination. Hence it may be considered to be primary form.
Routinely used diagnostic test of breast tuberculosis is detected by Ziehl Nielsen staining or by culture. However, histochemistry is not practical
Culture of M. tuberculosis has limitations due to the delay in obtaining the final result and the possibility of false-negative results in paucibacillary samples. 
Chest X-ray-
No lesion revealed.
USG-
Swelling reported as mastitis going
for early abscess formation.
Haemoglobin-
8.1 gm%.
CBC-
*WBC count- 6200/cu mm.
*Polymorphonuclear cells-50, Lymphocytes- 44.
*ESR- 60/hour.
LOCAL EXAMINATION
Swelling in the breast measuring 4x5 cms.
Location-present over the upper inner quadrant.
Cystic in consistency.
Local rise in temperature and erythema at the site.
Tender and fluctuation test positive.
No axillary lymphadenopathy.
FNAC-
*Revealed abundant acute inflammatory cells. *Mainly neutrophils, few lymphocytes.
*No evidence of granulomatous lesion or malignancy in the smear study.
ZN stain-
Multiple Acid fast bacilli are present.
CONCLUSION
Breast tuberculosis uncommon primary form , which poses diagnosis deliema and treatment challenge.
Hence it should be confirmed with the help of ZN stain and USG guided FNAC of any breast lump swelling with a strong family history of tuberculosis
Early diagnosis may lead to early and effective treatment of tuberculosis in such cases .
Gram’s stain –
Presence of pus cells but no organisms.
Bacteriological Culture-
No growth.
Molecular test-
*Gene expert- positive for Mycobacterium tuberculosis complex with Rifampicin sensitive.
REFERENCES
Spyridon Marinopoulos, Dionysia Lourantou, Thomas Gatzionis et al. Breast tuberculosis: Diagnosis, management and treatment. Int J Surg Case Rep. 2012; 3(11): 548–550.
Sonia Gon, Aditi Bhattacharyya, Bipasa Majumdar, Soumya Kundu. Tubercular Mastitis - A Great Masquerader. Turkish Journal of Pathology. 2013;29(1):
Sanjay Jain, Adesh Shrivastava, Dinesh Chandra. Breast lump, a rarepresentation of costochondral junction tuberculosis: a case report. Cases Journal 2009;7039(2):1-3.
AFTER INCISION AND DRAINAGE
Normal breast tissue
Acid fast bacilli