breast tuberculosis
Introduction
Introduction to breast tuberculosis Tuberculosis of breast, also known as tuberculous mastitis, is a chronic specific infection of the breast. This disease is rare, but it is not uncommon. In 1829, Cooper first described the disease. In China, the disease was first reported by Chen Yuming in 1930. Breast tuberculosis is common in lactating women, with primary (tubular tuberculosis of breast) and secondary (secondary tuberculosis of breast). The former is mostly caused by damage to the skin of the breast, which is often secondary to tuberculosis in the chest, or secondary to tuberculosis in other organs. Therefore, in the treatment of local breast lesions, systemic anti-tuberculosis treatment should also be carried out. Can be divided into nodular, fusion, hardened and other types. basic knowledge Proportion of disease: the probability of illness for women over 20 years old is 0.003% Susceptible people: women Mode of transmission: air, respiratory transmission, food transmission, vertical transmission Complications: Breast cancer Hodgkin's disease Anemia
Cause
Breast tuberculosis
Skin damage (30%):
This disease occurs mostly in lactating women. Because of the blood circulation and lymphatic circulation of the breast are significantly active, coupled with milk deposition, baby sucking caused by areola, nipple skin damage, is conducive to the retrograde spread of Mycobacterium tuberculosis and infection and disease. In direct infection, it can be directly infected from the breast skin wound and the dilated breast duct opening.
Low immune function (30%):
When the general health or immune function is low, such as severe malnutrition, trauma, etc., it is easy to cause tuberculosis infection. The source of tuberculosis infection is: systemic disseminated tuberculosis, such as tuberculosis of pulmonary miliary tuberculosis. Infection from the mediastinum, upper and lower lymph nodes of the clavicle, axillary lymph nodes, etc., retrograde invasion of the breast. Direct spread of tuberculosis infection in adjacent tissues and organs, such as ribs and chest wall tuberculosis.
Pathogenesis
1. The lesions of breast tuberculosis are more common in the breast, followed by the lower, the central is the least, most of the side of the disease, both sides of the disease is about 5%, the right side is slightly more than the left side.
2. Pathomorphology
(1) Gross morphology: Intradural induration can be seen in the early stage, the surface is smooth, the boundary is unclear, and it can be pushed. As the lesion progresses, the induration merges into a larger mass, and the incision can be seen in the center where necrosis occurs (cheese-like necrosis). The liquefaction forms a abscess cavity, and several abscesses communicate with each other to form a multiple abscess. If the skin is worn for a long time, the sinus is formed, the tuberculous pus flows out, the breast tissue is extensively destroyed, and the female breast tuberculosis in the middle-aged period Most of them develop into a sclerosing type of lesion. The fibrous tissue is seen in the cut surface of the tumor, and the central necrotic area is not large.
(2) Histological morphology: typical tuberculous infiltration in the breast tissue, typical tuberculous nodules can be seen, the center of the nodule is caseous necrosis, and the outermost layer is surrounded by lymphocytes and monocytes. Around, in the middle is the epithelioid cell area, there are a few megakaryocytes (Lanhans giant cells) between epithelioid cells, sometimes no typical tuberculous nodules can be found in tuberculous lesions, only in inflammatory infiltration More epithelial cells and a number of cheese-like necrosis.
Electron microscopy ultrastructural studies have demonstrated that macrophages phagocytose tubercle bacilli through the phagosome formed by cell membrane subsidence, and interact with primary lysosome containing hydrolase to develop phagosomes into digestive vacuoles or secondary lysozymes. body.
Prevention
Breast tuberculosis prevention
Breast tuberculosis is a kind of special inflammation, which is caused by the spread of tuberculosis in other organs. Active treatment of primary lesions can reduce the occurrence of breast tuberculosis.
Complication
Breast tuberculosis complications Complications Breast cancer Hodgkin's disease anemia
Breast cancer
Miller (1971) and Ward (1978) reported that about 5% of breast tuberculosis coexisted with cancer. Smith and Mason reported that 18 cases of breast tuberculosis and cancer coexist, so the diagnosis and treatment of this disease can not ignore the possibility of breast cancer.
2. Hodgkin's disease
Graemrcook (1988) reported that breast tuberculosis complicated with Hodgkin's disease is rare.
Anemia
When breast tuberculosis combines with other parts of the tuberculosis, it increases the consumption of systemic metabolism, and in severe cases, anemia can occur.
Symptom
Breast tuberculosis symptoms Common symptoms Breast lumps hypothermia abscess nodules calcified nipple retraction purulent secretion tuberculosis
Clinical classification
According to the pathological characteristics of breast tuberculosis, it is clinically divided into three types.
(1) Nodular type: more common in early cases, the lesion mainly invades the glandular tissue, which is characterized by localized tuberculous nodules. The nodules can be single or multiple, more rigid, smooth, active, and the boundary is unclear. Continue to increase, but still retain the nodular shape, or spread to the surrounding type to become a fusion type, tuberculous nodules are often the first symptom of the patient's visit, but also the main complaint of ulcer or sinus.
(2) fusion type: for the diffusion of a single nodule or the fusion of multiple nodules, a cheese-like liquefied mass, large destruction of breast tissue and extra-glandular tissue, often with the formation of multiple cold abscesses, or Self-breaking ulcers, or long-term unhealed fistulas, can also spill purulent secretions from the nipple, more common in lactating women, Yang Weiliang reported that 14 of 26 cases have this performance, 88 cases reported by Shi Songkui There are 44 cases with this performance.
(3) Hardening type: The tuberculosis lesions are mostly in the areola or its surroundings, the necrotic tissue in the center is less, and the fibrous tissue is more, which is a chronic disease with slower course of disease. Because the lesion can invade the lymph and breast suspensory ligament, the skin is often visible. There is an "orange peel" change and the skin "dimple sign" makes the nipples abnormal or retracted, similar to the characteristics of breast cancer.
(4) Others: In addition, there are acute miliary breast tuberculosis due to blood circulation and occlusive breast tuberculosis directly invaded by the milk duct, both of which are rare types.
2. Symptoms and signs
The progress of the disease depends on the nature of the disease, and the body reaction and the treatment are different. The literature reports that the shortest is only 2 weeks, the elderly are 20 years, most of them are 3 to 4 months, and the short course is mostly shallow induration. Early infiltration into the surrounding area, the disease course is long, the lesions are mostly in the deep part of the breast tissue, the development is slow and concealed, so that it fails to attract attention.
(1) breast lumps: breast lumps are often the main reason for the treatment, which is characterized by isolated nodules in the breast, no pain, no obvious boundary, the breast itself generally does not increase, after a period of stable time, the nodules gradually increase, soft Hard and irregular, the boundary and surface skin may have mild pain, edema and dark red changes and other chronic inflammatory reactions due to infiltration and adhesion. Some breasts have "orange peel" changes, such as the mass near the areola or the areola Infiltration, there are often nipple retraction or abnormal breast axis, which is similar to breast cancer performance.
(2) fistula formation: treatment does not promptly soften the mass to form a cold abscess, abscess ulceration, pus discharge from the bean dregs-like debris, the milk duct cavity and the skin can form a breast fistula or a large ulcer, the patient can be accompanied by the whole body Low fever, ipsilateral axillary lymph nodes.
(3) nipple discharge: lesions invade the milk duct, pus can be discharged from the nipple, if not combined with general infection, this pus for Gram stain, no positive bacteria in microscopic examination, for acid-fast staining, occasionally found Acid-fast bacilli, both can be used as a basis for identifying general infections and tuberculosis infections.
(4) Breast deformation: If the mass does not soften and the fibrous tissue hyperplasia occurs, the mass becomes hard, the breast can be severely deformed, the nipple is invaginated, and some breast skin can have a dimple sign, which is easily misdiagnosed as breast cancer, but because of The course of the disease is slow, the mass is large and small, and the characteristics of abscess formation can be identified.
(5) Symptoms of poisoning: Most patients have no symptoms of tuberculosis poisoning. Only when combined with tuberculosis lesions in other areas, such as tuberculosis, cervical lymphatic tuberculosis, kidney and other active tuberculosis, there are obvious symptoms of poisoning, which are characterized by low fever, palpitations, and body aches. , weak and weak, etc., severe tuberculosis can be complicated by anemia.
Examine
Breast tuberculosis check
1. Blood routine white blood cells are normal or slightly higher, and the number of eosinophils is increased.
2. Erythrocyte sedimentation rate can be accelerated.
3. Cytological examination Take a pus or cheese-like necrotic smear for acid-fast staining, sometimes find tuberculosis.
4. Histopathological examination of pus microscopic examination showed necrotic tissue debris without pus cells, nodular microscopy, the center is a caseous necrotic area, the outer layer is surrounded by lymphocytes and monocytes, and the middle is epithelioid cells. There are a few multinucleated giant cells (Lanhans giant cells) in the area.
5. Mammogram
(1) nodular type: the most common, manifested as single or multiple nodules dense shadow, round, oval or lobulated, mainly composed of multiple unclear tuberculous abscesses, most of which are 2 ~ 3cm, the edge of the nodule is generally smooth, there may be calcification around, the growth is very slow, from the development speed can be excluded from the cancer, some cases due to the proliferation of fibrous tissue around the lesion to form burrs, it is somewhat like cancer. Breast cancer is not easy to distinguish.
(2) Hardening type: It shows a uniform and dense mass shadow, which can be separated by fiber, nipple retraction, but lacks calcification; or star structure, easy to be confused with breast cancer.
(3) fusion type: the lesion is close to the chest wall, diffusing along the base of the breast, early exudative lesions, showing a limited flaky infiltrates, blurred edges, gradually diffuse, late lesions are more extensive, can be mixed with necrotic liquefaction zone and scattered Calcification, lesions can also be merged into a huge mass, the translucent shadow of the subcutaneous fat layer disappears, sometimes see skin thickening.
6. B-ultrasound examination of single or multiple hypoechoic masses, the mass of the tumor is thick, the boundary is still clear, and some of the envelope echoes are seen (Fig. 4). When the abscess is formed, irregular dark areas of different sizes can be seen in the mass. When the ulcer sinus is formed, the mass breaks back into the muscle wall of the chest wall, communicates with the chest cavity, and sees the dark area in the chest cavity; or breaks through the skin, the fistula is open to the outside, and the cheese-like flow is seen when squeezed, and the whole breast is obviously increased. Large, diffuse mass-like changes, low echo, visible small dark areas and strong light spots.
7. Infrared or MRI has guiding significance for the diagnosis of this disease.
Diagnosis
Breast tuberculosis diagnosis
diagnosis
A painless mass of breast in young and middle-aged people, early cytological examination and acid-fast staining to find tubercle bacilli to identify breast cancer; late sinus or ulcer surface is red dark red, skin edge sneak and loose, pale Granulation, microscopic examination of pus can be seen necrotic tissue debris without pus cells, tuberculosis can sometimes be found after pus staining, mammogram shows large calcification, helpful for diagnosis, tumor section for pathological examination is to diagnose breast The most accurate method of tuberculosis is to find that tuberculosis or rib tuberculosis in the lungs is also helpful in diagnosis.
Differential diagnosis
Early breast tuberculosis is still difficult to distinguish from breast cancer. Hinton reported that 8 cases were misdiagnosed as breast cancer and underwent radical surgery. Shpley and Sencer reported 10 cases and 5 cases were misdiagnosed. Ye Zongdian reported that half of the outpatient clinics were misdiagnosed as breast cancer. Among the 88 cases of breast tuberculosis, 51 cases were misdiagnosed as breast cancer, accounting for 57.9%; only 9 cases were diagnosed as breast tuberculosis, accounting for 10.2%; 16 cases (18.3%) and 12 were diagnosed as benign tumors and inflammation. The case (13.6%) indicates that the early diagnosis of this disease is not easy, so it is necessary to pay attention to the differential diagnosis.
1. Breast cancer has the following characteristics compared with breast cancer:
(1) More common in young and middle-aged people, 20 to 40 years old, especially in pregnant and lactating women, and a long history, slow progress.
(2) Some cases have primary lesions, such as hilar lymphatic tuberculosis, axillary or cervical lymphatic tuberculosis, chest wall and spinal lymphatic tuberculosis, etc., and breast cancer coexists with this.
(3) More than half of the patients have chronic inflammation, local skin ulceration, sinus formation, thin discharge, pus-like pus, no stench, breast cancer ulcers with cauliflower or malignant ulcers with raised edges. There is a bad smell, breast tuberculosis sinus effluent smear for acid-fast staining, can be found tuberculosis.
(4) Early stage of breast tuberculosis develops rapidly, local reaction is heavy, lymph node enlargement occurs earlier, but the texture is softer; breast cancer has relatively slow development, but the course of disease is shorter, more painless, axillary lymphoma and hard .
(5) Although sclerosing breast tuberculosis also has nipple retraction, lumps and skin adhesions, painless and other clinical manifestations similar to breast cancer, but the age of breast tuberculosis is 10 to 20 years younger than breast cancer.
(6) X-rays have nodular shadows with unclear boundaries and flaky calcifications.
(7) Histopathological examination helps to identify breast cancer and confirm the diagnosis.
2. Breast fat necrosis
(1) The local manifestations of breast fat necrosis are similar to tuberculosis, but patients with breast fat necrosis are more common in obese middle-aged and elderly women. Generally, the history of trauma can be found, and the skin of the wound appears ecchymosis.
(2) The oil sac can be seen in the cut surface of the breast fat necrosis, and the liquefied fat or brown blood liquid can be seen in the sac; the typical caseous necrosis in the tissue of the breast tuberculosis can be found in the tuberculosis; the pathological tissue section can be seen in the typical Tuberculous nodules; this is not the case in the pathology of breast fat necrosis.
(3) Breast fat necrosis does not form chronic ulcers and sinus and cold abscesses.
3. Breast filariasis
(1) Breast filariasis is more common in women in filariasis endemic areas.
(2) The residual part of the silkworm worm and the bleeding can be found in the breast lumps.
4. Breast sarcoidosis
(1) Breast sarcoidosis often invades the whole dermis, rarely invades deep tissues, eczema-like small papules appear on the epidermis, skin thickens and roughs, and the center of the papules subsides to make the lesions ring.
(2) There is no induration in the milk of breast sarcoidosis, no pus, no sinus.
(3) X-ray films showed obvious tuberculoma-like images or huge masses, and there were unclear calcifications around them.
(4) Case-like necrosis was not observed on the pathological tissue sections of breast sarcoidosis.
(5) The tuberculin test of breast tuberculosis was positive.
