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\begin{document}

\title{Fine needle aspiration cytology-based accurate and rapid diagnosis of
breast tuberculosis masquerading as a case of abscess}



\author[1]{Vityala Yethindra}%
\author[2]{Altynai Zhumabekova}%
\author[3]{Cholpon  Dzhumakova}%
\author[4]{Tugolbai Tagaev}%
\author[3]{Asel Namazbekova}%
\author[4]{Bolotbek Djanaliev}%
\affil[1]{International Higher School of Medicine}%
\affil[2]{City Maternity Hospital No. 2}%
\affil[3]{National Center of Oncology and Hematology}%
\affil[4]{I K Akhunbaev Kyrgyz State Medical Academy}%


\vspace{-1em}



  
  \date{May 18, 2024}


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\selectlanguage{english}
\begin{abstract}
We are reporting a case of breast tuberculosis (BT) that was initially
misdiagnosed as a breast abscess. Fine needle aspiration cytology (FNAC)
helped in diagnosing BT faster by avoiding different invasive diagnostic
methods. FNAC can be used as the primary diagnostic method of choice for
the diagnosis of BT.%
\end{abstract}%



\sloppy


\textbf{Fine needle aspiration cytology} -\textbf{based accurate and
rapid diagnosis of breast tuberculosis masquerading as a case of
abscess}

Vityala Yethindra\textsuperscript{1*}, Altynai
Zhumabekova\textsuperscript{2}, Cholpon Dzhumakova\textsuperscript{3},
Tugolbai Tagaev\textsuperscript{4}, Asel Namazbekova\textsuperscript{5},
Bolotbek Djanaliev\textsuperscript{6}

\textsuperscript{1}Department of Pathology, International Higher School
of Medicine, International University of Kyrgyzstan, Bishkek, Kyrgyzstan

\textsuperscript{2}Obstetrician-gynecologist, City Maternity Hospital
No. 2, Bishkek, Kyrgyzstan

\textsuperscript{3}Department of Gastroenterology, National Center of
Oncology and Hematology, Bishkek, Kyrgyzstan

\textsuperscript{4}Department of Public Health and Healthcare, I.K.
Akhunbaev Kyrgyz State Medical Academy, Bishkek, Kyrgyzstan

\textsuperscript{5}Department of Cancer registry, National Center of
Oncology and Hematology, Bishkek, Kyrgyzstan

\textsuperscript{6}Department of Pathological Anatomy, I.K. Akhunbaev
Kyrgyz State Medical Academy, Bishkek, Kyrgyzstan

\textbf{Running title:} Fine needle aspiration cytology as the primary
diagnostic method of breast tuberculosis

*Corresponding author: Vityala Yethindra, Department of Pathology,
International Higher School of Medicine, International University of
Kyrgyzstan, Bishkek, Kyrgyzstan,
Email:\emph{yethindravityala10@gmail.com}, Contact: +91 9121925658

\textbf{ABSTRACT}

We are reporting a case of breast tuberculosis (BT) that was initially
misdiagnosed as a breast abscess. Fine needle aspiration cytology (FNAC)
helped in diagnosing BT faster by avoiding different invasive diagnostic
methods. FNAC can be used as the primary diagnostic method of choice for
the diagnosis of BT.

\textbf{Keywords:} Breast tuberculosis, Fine needle aspiration cytology,
Antitubercular therapy.

\textbf{Key clinical message}

In patients with breast tuberculosis (BT), fine-needle aspiration
cytology functions as a primary diagnostic method to guide the
appropriate management of initial earlier in the course and helps in
preventing the wider spread of BT.

\textbf{INTRODUCTION}

In 1829, the earliest breast tuberculosis (BT) case was reported by Sir
Astley Cooper and mentioned as ``scrofulous swelling of the
bosom''.\textsuperscript{1} BT is a rare and uncommon presentation of
tuberculosis\textsuperscript{2} with an 0.1\% overall incidence in
breast lesions in developed and 4\% in surgically treated lesions in
developing countries.\textsuperscript{3,4} BT is excluded and at times
over-diagnosed as breast cancer or abscess.\textsuperscript{5,6} BT is
recognized substantially in women of reproductive age, lactating,
multiparous, and sometimes also seen in men (4.5\% of
cases)\textsuperscript{4,7}; it coexists with immunodeficiency states
like HIV.\textsuperscript{8} Primary BT is very
rare\textsuperscript{9}and secondary BT arises due to hematogenous,
retrograde (axillary lymph nodes), or direct spread (lung, pleura,
mediastinum, and articular lesions).\textsuperscript{10} In this study,
we describe a case of an immunocompetent patient with no evidence of any
other tubercular foci in the body.

The objective of this report was to emphasize the significance of
fine-needle aspiration cytology (FNAC) as the primary diagnostic method
of choice in the diagnosis of BT and the avoidance of different invasive
diagnostic methods.

\textbf{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\selectlanguage{ngerman}×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.\textsuperscript{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.

\textbf{DISCUSSION}

Historically, clinical manifestations of BT have been observed within 1
year, but they range from months to years.\textsuperscript{11} BT
commonly affects women aged from 20-50 years,\textsuperscript{4,12}which
is equivalent to the higher prevalence of pulmonary tuberculosis seen in
a similar age women.\textsuperscript{13} In our report, the patient was
a 34-year-old woman presenting with symptoms for 2 months.

BT regularly presents as a lump\textsuperscript{14} in the central or
upper outer quadrant of the breast.\textsuperscript{15} In our patient,
the lump was present in the upper outer quadrant of the right breast.
Manifestation is inconsistent, frequently as a round nodular lump with
tissue induration, with fistula formation, but they are infrequently
connected with pain. Our patient had diffuse ulceration, pain, and a
lump in the right breast.

Tubercular ulcers over the breast skin and tubercular breast abscess
with or without discharging sinuses are even common forms of
presentation of BT.\textsuperscript{13} Our patient presented with a
unilateral draining sinus.

BT was classified earlier as: Nodular, disseminated, sclerosing,
obliterans, and acute miliary tubercular
mastitis.\textsuperscript{14}The sclerosing, obliterans, and miliary
types are of historical significance and currently BT could be
reclassified as nodular, disseminated, or abscess. The BT in our patient
belonged to the abscess variety.

BT lesions have no specific US findings and are visualized as
heterogeneous, hypoechoic, irregularly bordered with internal
echoes.\textsuperscript{16} Diagnosis is optimally based on the
confirmation of AFB in the breast tissue by ZN
staining.\textsuperscript{17} In this study, Doppler US showed features
of breast abscess, while FNAC showed epithelioid granulomas with AFB
positivity on ZN staining.

FNAC is a trustworthy diagnostic procedure, in which aspirated material
is subjected to staining for revealing AFB\textsuperscript{18} and
diagnosing BT.\textsuperscript{17} In BT cases, FNAC evaluation has
accurately diagnosed the cases as BT in 73\% of the cases evaluated
using histopathology as having both epithelioid granulomas and
necrosis.\textsuperscript{19} In this study, histology revealed the
presence of Langhans giant cells, epithelioid cell granulomas, and
caseous necrosis; FNAC was diagnostically useful for BT.

Trepan biopsy showed a decent positive result. However, inci-/excisional
biopsy of breast lumps, ulcers, and sinuses, or a suspected tubercular
breast abscess cavity wall mostly diagnoses BT.\textsuperscript{17,19}In
this patient, an excision biopsy was suggested, but the patient and her
attendants refused the procedure.

Even though tests such as QuantiFERON\selectlanguage{english}-TB Gold-In tube have high
sensitivity (97.9\%) and specificity (98.1\%),\textsuperscript{20} there
are many limitations such as false-negative results in extrapulmonary
tuberculosis (28.8\%)\textsuperscript{21} and inability to discriminate
latent tuberculosis from active tuberculosis
infection.\textsuperscript{22} In this study, FNAC evaluation paved the
way for an accurate diagnosis.

BT could show a diagnostic difficulty in radiological and
microbiological diagnosis, and consequently, high degree of suspicion
are required. BT is treatable with ATT,\textsuperscript{23} and surgical
intervention is needed in rare situations.

\textbf{ACKNOWLEDGMENTS}

The authors acknowledge their patient for kind cooperation and for
providing consent.

\textbf{FINANCIAL SUPPORT}

No financial support was received for the study.

\textbf{CONFLICT OF INTEREST}

The authors declare no conflicts of interest.

\textbf{AUTHOR CONTRIBUTIONS}

Conception, design of the work, manuscript preparation, and data
acquisition: Vityala Yethindra, Tugolbai Tagaev, Asel Namazbekova,
Clinical management: Altynai Zhumabekova, Cholpon Dzhumakova, and
Manuscript preparation and data acquisition: Vityala Yethindra, Tugolbai
Tagaev, Bolotbek Djanaliev.

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