Abstract
Background: Breast tuberculosis is a rare extra pulmonary tuberculosis presentation usually misdiagnosed as carcinoma, pyogenic abscess or idiopathic granulomatous mastitis. Detection of tubercular bacilli by ZN stain, culture and CBNAAT along with caseating granuloma on histopathology helps in diagnosis.
 Aims and Objectives: To study the clinico-pathological characteristic of breast tuberculosis and diagnostic accuracy of CBNAAT for early and specific diagnosis in reference to histopathological test
 Material and Methods: 38 cases of BTB between August2012 to July 2017 were studied. Culture for acid-fast bacilli, smear positivity on Z-N staining, CBNAAT, and cytological and histological examination was done for confirmation.
 Results: Prevalence of BTB in this study was found to be 3.95% .The risk factors were reproductive age (20-35), multiparity, lactation and low socioeconomic status. Unilateral lump in the upper outer and central quadrant of the breast was the commonest observation. Only 34.2% were diagnosed provisionally as BTB rest 73.68% were misdiagnosed as fibroadenoma, breast abscess and malignancy Clinically nodulo-caseous variety(55.6 %) disseminated (18.4%) and tubercular abscess (26.3%) were seen. Sensitivity of ZN staining, culture, FNAC and histopathology is 15.8%,5.8%, 74% ,100%respectively. Sensitivity, specificity, positive predictive value, and negative predictive value for the CBNAAT test were 81.818%, 93.103%, 93.10%, and 81.82% respectively.39.4% were cured completely with ATT with 60.52% with residual lesions needed surgery
 Conclusion: This study highlights the importance of early diagnosis and aggressive medical and if required surgical management to cure this disease. CBNAAT should be used as an additional test to conventional smear microscopy, culture, FNAC and histology.
 Keywords: Breast tuberculosis, CBNAAT, Extrapulmonary tuberculosis, breast lump
Highlights
Tuberculosis is a global public health problem disease with extra-pulmonary form of tuberculosis accounting for only 18% of global prevalence.(1).Breast tuberculosis (BTB) is a very rare form of extra pulmonary tuberculosis (EPTB) persisting even today, since Sir Astley Cooper first described it in 1829.(1).The incidence of this rare clinical entity is less than 0.1% in developed countries and 3-4.5% of breast lesions in endemic countries like India.(1)The incidence of EPTB is on the rise worldwide due to increasing prevalence of immunosuppressive diseases and multidrug resistance tuberculosis but still, BTB constitutes only 0.1% of EPTB.(2,3)The non-specific clinical and imaging characteristics and lack of familiarity of clinicians with this rare entity along with non-availability of confirmatory test have led to increased rates of underreporting and underdiagnoses
CBNAAT should be used as an additional test to conventional smear microscopy, culture, Fine needle aspiration cytology (FNAC) and histology
Diagnosis of BTB is done by as clinic-radiological suspicion, FNAC and histopathological examination, culture for acid fast bacilli (AFB) and Z-N staining as per International Standards for Tuberculosis Care.(12) The gold standard diagnostic test of BTB is detection of AFB by ZN staining by microscopy or by solid or liquid culture accounting for 12% positivity by ZN staining and 26% by culture is in various studies and but we found it to be 6% and 15.8% respectively due to paucibacillary samples.(6,9)
Summary
The non-specific clinical and imaging characteristics and lack of familiarity of clinicians with this rare entity along with non-availability of confirmatory test have led to increased rates of underreporting and underdiagnoses As it simulates with more common breast lesions such as breast carcinoma, pyogenic abscess, fibroadenoma, duct ectasia and other granulomatous and fungal diseases, it poses a diagnostic challenge.(1,2) Resistance of breast tissue to the survival and multiplication of tubercular bacilli may be the cause of this 9|Page. A misdiagnosis and delayed diagnosis is a misfortune for the patient as BTB can be completely cured conservatively by drugs whereas treatment of the differential diagnosis varies from steroid to major disfiguring surgeries like mastectomy.(2) A major breakthrough in the diagnosis of EPTB has been achieved by the introduction of CBNAAT which a rapid, automated, cartridge based nucleic acid amplification assay detecting nucleotide sequences unique to M. tuberculosis directly in the specimens and gives results within few hours It is used for simultaneous detection of Mycobacterium tuberculosis complex and rifampicin resistance accurately in EPTB. Detection of tubercular bacilli by ZN stain, culture and CBNAAT along with caseating granuloma on histopathology helps in diagnosis
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