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Letter to the Editor
Isolated Primary Breast Tuberculosis - Report of Three Cases and Review of the Literature
Meral SenI,
Corresponding author
drmeralsen@yahoo.com

Tel: 00903122035105
, Canan GorpeliogluII, Mikdat BozerI
I Fatih University School of Medicine, Department of General Surgery - Ankara/Turkey
II Fatih University School of Medicine, Department of Dermatology - Ankara/Turkey
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="para10" class="elsevierStylePara elsevierViewall">Tuberculosis &#40;TB&#41; is a very old disease&#44; and tuberculosis bacilli have co-existed with humans as far back as 5000 BC&#44; according to studies of the spine TB lesions &#40;Pott&#8217;s disease&#41; from Egyptian mummies&#46;<a class="elsevierStyleCrossRef" href="#bib1">1</a> TB continues to be a frequent cause of mortality and morbidity&#44; with an incidence rate of 150 cases per 100&#44;000 people in 2005&#46; Currently&#44; one person becomes newly infected every second worldwide&#46;<a class="elsevierStyleCrossRef" href="#bib2">2</a></p><p id="para20" class="elsevierStylePara elsevierViewall">TB mostly affects the lungs as it is an airborne infectious disease&#44; but any organ can be affected as a result of hematogenous spread&#46; It has been suggested that some organs and tissues like the mammary gland tissue and spleen offer resistance to the survival and multiplication of tuberculosis bacillus&#46;<a class="elsevierStyleCrossRef" href="#bib3">3</a> Hence&#44; tuberculosis of the breast is an uncommon disease&#44; with an incidence between 0&#46;1&#37;&#8211; 3&#37; of all breast diseases treated surgically&#46;<a class="elsevierStyleCrossRef" href="#bib4">4</a> Its incidence is likely to be higher in undeveloped countries as a result of the high TB incidence&#44; but with an increasing spread of HIV in developed countries&#44; this pattern of incidence may change&#46; TB is a very rare disease&#44; so a high level of suspicion is required to make the diagnosis&#46; Breast TB can mimic breast carcinoma or breast abscess&#44; clinically and radiologically&#46; Concomitant axillary lymph nodes were found in one-third of the patients with breast TB&#46;<a class="elsevierStyleCrossRef" href="#bib5">5</a> This paper presents three cases to argue that breast TB should be included in the differential diagnosis of breast lesions&#44; like breast carcinoma&#44; persistent breast abscess and infectious patterns with fistulizations&#44; especially for patients from high risk populations and endemic regions&#46;</p><span id="cesec10" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle10">CASE PRESENTATIONS</span><span id="cesec20" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle20">Case-1</span><p id="para30" class="elsevierStylePara elsevierViewall">A 26-year-old female patient presented with painful swelling&#44; with multiple discharging sinuses of the right breast and a palpable lump in her right breast&#46; According to the patient&#44; the lump had been present for the past six to seven months&#44; and the sinuses had developed recently &#40;<a class="elsevierStyleCrossRef" href="#fig1">Fig-1</a>&#41;&#46; On physical examination&#44; the right breast was very tender&#44; and a diffuse&#44; irregular mass was felt&#44; mainly involving the lower quadrants&#46; There overlying skin was discolored&#44; with multiple sinuses discharging a dirty yellow fluid&#46; The patient was treated with several nonspecific antibiotics by her family physician&#44; but her breast symptoms remained the same&#46; With these signs and symptoms&#44; she was admitted to our general surgery department&#46; The patient&#8217;s laboratory data was 11&#46;600 leukocytes&#47;mm3 and an ESR of 70 mm&#47;hr&#46;</p><elsevierMultimedia ident="fig1"></elsevierMultimedia></span><span id="cesec30" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle30">Case-2</span><p id="para40" class="elsevierStylePara elsevierViewall">A 30-year-old female patient presented with a 2-month history of a painful erythematous left breast lump&#44; with an associated sinus tract&#46; She had received several empiric antibiotics and had previously undergone drainage of the breast lesion on several occasions&#44; but her symptoms persisted&#46; She had delivered her third baby 13 months earlier&#46; On breast examination&#44; a large tender mass was felt in the inner half of the left breast&#46; A sinus tract was felt near the nipple and it was freely mobile&#44; with no axillary nodes &#40;<a class="elsevierStyleCrossRef" href="#fig2">Fig-2</a>&#41;&#46;</p><elsevierMultimedia ident="fig2"></elsevierMultimedia></span><span id="cesec40" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle40">Case-3</span><p id="para50" class="elsevierStylePara elsevierViewall">A 43-year-old woman was admitted to our hospital with complaints of swelling&#44; breast lump and erythema of the skin in her right breast&#44; which appeared 45 days earlier&#46; On physical examination&#44; a 6- to 7-cm&#44; firm and mobile mass was observed&#44; which caused erythema and edema of the skin in the inner lower quadrant of the left breast&#46; There was no fistulization&#46; Ultrasonography examination revealed a hypoechoic mass with significant ductal dilatation without collection and lymphadenopathy&#44; which suggested mastitis&#46;</p><p id="para60" class="elsevierStylePara elsevierViewall">All three patients denied smoking&#44; having risk factors for HIV or a recent exposure to tuberculosis&#46; They had no past history of tuberculosis&#44; and they had no family history of breast cancer&#46; Tuberculin skin test results &#40;Mantoux&#41; were 16&#44; 13 and 14 mm for cases 1&#44; 2 and 3&#44; respectively&#46; Their routine hematologic and biochemical parameters were in the normal range&#44; including negative testing for HIV&#46; Their erythrocyte sedimentation rates were also normal&#46; Their sputum smears and discharge materials from the breast were found to be negative for acid-fast bacilli &#40;AFB&#41;&#44; both in culture and by PCR&#46; All of their chest X-rays were normal&#46; Both trucut and fine needle biopsy were applied to their breast lesions&#46; Their pathological examinations showed chronic granulomatous inflammation with areas of central necrosis&#44; epithelioid granulomas with Langhans giant cells and lymphohistocytic aggregates suggestive of tuberculosis &#40;<a class="elsevierStyleCrossRef" href="#fig3">Fig-3</a>&#41;&#46; The patients were all diagnosed as breast tuberculosis according to pathological examinations&#46; The intensive therapy with anti-tuberculosis drugs &#40;isoniazid 300 mg&#44; rifampicin 600 mg&#44; pyrazinamide 1500 mg and ethambutol 1000 mg per day&#41; was initiated for 2 months and continued with the addition of rifampicin and isoniazid therapy for an additional four months&#46; With treatment&#44; their breast lesions and tenderness steadily improved&#46; Cures were obtained for all patients at the end of the sixth month period&#46;</p><elsevierMultimedia ident="fig3"></elsevierMultimedia></span></span><span id="cesec50" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle50">DISCUSSION</span><p id="para70" class="elsevierStylePara elsevierViewall">In 1829&#44; Sir Astley Cooper defined breast tuberculosis as the &#39;scrofulous swelling of the bosom&#8217;&#46;<a class="elsevierStyleCrossRef" href="#bib6">6</a> The lump is the most common presentation in breast tuberculosis&#46;<a class="elsevierStyleCrossRef" href="#bib7">7</a> These breast lumps are mostly misdiagnosed as fibroadenoma&#44; fibroadenosis&#44; malignancy or breast abscess&#46; The three main features of breast TB are nodular&#44; disseminated and sclerosing&#44; and these features result in multiple discharging sinuses&#44; lumps&#44; ulcers and recurring abscesses of the breast are observed&#46; Tubercular lumps are mostly irregular&#44; ill-defined and mostly more painful than that seen in carcinoma&#46; Pain is usually dull and constant in breast TB&#46; In Puneet&#8217;s series&#44;<a class="elsevierStyleCrossRef" href="#bib7">7</a> 12 patients were clinically misdiagnosed as fibroadenoma&#44; 17 as fibroadenosis and 8 as carcinoma&#46;</p><p id="para80" class="elsevierStylePara elsevierViewall">Breast tuberculosis commonly affects young multiparous&#44; lactating women&#46; Although cases have been reported from age 6 months to 73 years&#44; most were between 20 to 40 years old&#46;<a class="elsevierStyleCrossRef" href="#bib8">8</a>&#44;<a class="elsevierStyleCrossRef" href="#bib9">9</a> All of these cases were multiparous&#44; and their mean age was 33 years&#46; According to Wilson&#44;<a class="elsevierStyleCrossRef" href="#bib10">10</a> the right and left sides of the breast were involved equally often&#46; In contrast&#44; Pal<a class="elsevierStyleCrossRef" href="#bib11">11</a> reported that there is a slight tendency for the right breast to be more frequently affected as it was in our patient series&#46; Sharma<a class="elsevierStyleCrossRef" href="#bib12">12</a> found that the duration of symptoms ranged from 6 months to 2 years&#44; and in the case series of Khanna&#44;<a class="elsevierStyleCrossRef" href="#bib13">13</a> the mean duration of symptoms was 8&#46;5 months&#46;</p><p id="para90" class="elsevierStylePara elsevierViewall">Breast TB may be considered primary when no other demonstrable focus exists&#44; and may be considered secondary when a preexisting lesion is located elsewhere&#46; <span class="elsevierStyleItalic">M&#46; tuberculosis</span> can spread to the breast by the lymphatic and hematogenous routes or directly&#44; and it can persist for long periods within the body&#46; It is generally thought that the breast gets involved in tuberculosis by retrograde lymphatic extension from the mediastinal&#44; axilla and cervical region&#44;<a class="elsevierStyleCrossRef" href="#bib13">13</a> but in the cases reported here&#44; there was no associated lympadenopathy as confirmed by physical exam and ultrasonography and no other foci of tuberculosis infection&#44; and all chest x-rays were normal&#46; Direct infection of the breast may occur through skin abrasions or through the milk duct openings&#46; All three patients were in their reproductive ages with multiple children&#44; all of whom were breastfed for at least 6 months&#46; Lactation is known to increase the susceptibility of the breast to tuberculosis since during lactation&#44; the increased vascularity of the breast may facilitate infection and dissemination of the bacilli&#46; Shinde<a class="elsevierStyleCrossRef" href="#bib5">5</a> found that 7&#37; of their patients were lactating at the time of presentation&#44; while Banerjee<a class="elsevierStyleCrossRef" href="#bib3">3</a> reported that 33&#37; of their patients were lactating&#46; Two of these patients had recent lactation history&#46;</p><p id="para100" class="elsevierStylePara elsevierViewall">Although it is very specific and acts as the gold standard for the diagnosis&#44; <span class="elsevierStyleItalic">M&#46; tuberculosis</span> stain&#44; culture or PCR is not very sensitive&#44; and this may cause some additional delays for diagnosis and under-diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib14">14</a> Bacteriological examination of discharge from the sinus was negative for <span class="elsevierStyleItalic">M&#46; tuberculosis</span> on staining as well as culture in most cases&#46;<a class="elsevierStyleCrossRef" href="#bib15">15</a> However&#44; all of these cases had breast TB&#44; as they responded to antituberculosis treatment&#46; The bacteriological results were negative for staining&#44; culture and polymerase chain reaction &#40;PCR&#41; tuberculosis tests&#46; Environmental conditions can alter the physiology and virulence of <span class="elsevierStyleItalic">M&#46; Tuberculosis</span>&#44; since it requires oxygen for its growth and survival&#46; As the mammary gland tissue may convey some resistance to the survival and multiplication of the tuberculosis bacillus&#44; we expected that the number of <span class="elsevierStyleItalic">M&#46; tuberculosis</span> bacilli in the tissue would be small&#44; making it difficult to prove their existence&#46; On the other hand&#44; an AFB-positive smear can be seen from other mycobacteria species&#44; so it is not a definitive mycobacterial diagnosis for TB&#46; Most of the time&#44; pathological examinations are more valuable than bacteriological examinations and are preferred for the accurate diagnosis of breast TB&#46; Khanna<a class="elsevierStyleCrossRef" href="#bib13">13</a> found that in 52 patients with breast TB&#44; fine needle aspiration cytology &#40;FNAC&#41; was 100&#37; reliable in diagnosing breast TB&#46; A newly developed T-cell&#8211;based&#44; whole-blood enzyme-linked immunosorbent interferon release assay detects interferon&#46; Interferon is secreted by T cells in response to antigens encoded in the region of difference 1 of <span class="elsevierStyleItalic">M&#46; tuberculosis</span>&#44; a genomic segment absent from Calmette&#8211;Guerin bacilli and most environmental mycobacteria&#46; Thus&#44; the test confers a higher specificity than the tuberculin skin test&#46;<a class="elsevierStyleCrossRef" href="#bib16">16</a> Moreover&#44; results are available in 24 hours&#46; Unfortunately&#44; we could not perform these tests in our hospital&#46;</p><p id="para110" class="elsevierStylePara elsevierViewall">Histopathological confirmation of breast TB requires cytological evidence of caseous necrosis epitheloid granulomas and Langhans giant cells with lymphohistocytic aggregates&#46; The differential diagnosis of breast TB includes other granulomatous inflammatory diseases&#44; such as idiopathic granulomatous mastitis &#40;GM&#41;&#44; sarcoidosis&#44; Wegener&#8217;s granulomatosis and giant cell arteritis&#44; as well as other infections like actinomycosis and fat necrosis&#46; In idiopathic GM&#44; the granulomatous inflammatory reaction&#44; consisting of epitheloid and giant cells&#44; is confined to the breast lobules in which there is also leukocyte infiltration and abscesses but no caseation&#46;<a class="elsevierStyleCrossRef" href="#bib17">17</a> In breast TB&#44; the distribution of granulomas is diffuse and is not limited to the lobules&#44; and they are accompanied by caseation necrosis&#46; This necrosis results in the characteristic fistulization of skin lesions&#46; In plasma cell mastitis&#44; there is inflammation in the breast tissue in response to the irritating quality of fatty material accumulated in dilated ducts&#46; The granulomatous reaction in traumatic fat necrosis is confined to the broken down fat globules&#46; Fat necrosis can also be eliminated as a diagnosis by the absence of fat globules&#46; With appropriate serological investigation&#44; arteritis&#44; the absence of sulfur granules in the discharge of the sinus of the suppurating lesions and actinomycosis can all be eliminated from the differential diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib18">18</a></p><p id="para120" class="elsevierStylePara elsevierViewall">Radiological imaging modalities like mammography or ultrasonography are unreliable in distinguishing tuberculosis mastitis from carcinoma because of its nonspecific features&#46;<a class="elsevierStyleCrossRef" href="#bib19">19</a> Similarly computed tomography and magnetic resonance imaging are not diagnostic without histological confirmation&#46;</p><p id="para130" class="elsevierStylePara elsevierViewall">Immunosuppressive conditions&#44; like organ transplantations and HIV infections&#44; advanced age&#44; and chronic diseases&#44; increase the chance that tuberculosis presents atypically with extrapulmonary manifestations that can result in delays in diagnosis and treatment&#46; A high degree of clinical suspicion and familiarity with physical examination findings are necessary to enable an early diagnosis&#46; This requirement for familiarity motivated us to present our experience with breast TB to increase the awareness of other doctors of this condition&#44; and to enable the prevention of delays in the diagnosis of breast TB and of unnecessary interventions and surgical procedures&#46;</p></span></span>"
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                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib2"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:1 [
                  "host" => array:1 [
                    0 => array:1 [
                      "WWW" => array:1 [
                        "link" => "http&#58;&#47;&#47;www&#46;who&#46;int&#47;mediacentre&#47;factsheets&#47;fs104&#47;en&#47;index&#46;html"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib3"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Tuberculous mastitis&#58; a continuing problem"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => """
                              SN Banerjee \n
                              \t\t\t\t\t\t\t\t
                              """
                            1 => """
                              N Ananthakrishnan \n
                              \t\t\t\t\t\t\t\t
                              """
                            2 => """
                              RB Mehta \n
                              \t\t\t\t\t\t\t\t
                              """
                            3 => """
                              S Parkash \n
                              \t\t\t\t\t\t\t\t
                              """
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/BF01658471"
                      "Revista" => array:6 [
                        "tituloSerie" => "World J Surg"
                        "fecha" => "1987"
                        "volumen" => "11"
                        "paginaInicial" => "105"
                        "paginaFinal" => "109"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/3811379"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib4"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Tuberculous mastitis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => """
                              U Jalali \n
                              \t\t\t\t\t\t\t\t
                              """
                            1 => """
                              S Rasul \n
                              \t\t\t\t\t\t\t\t
                              """
                            2 => """
                              A Khan \n
                              \t\t\t\t\t\t\t\t
                              """
                            3 => """
                              N Baig \n
                              \t\t\t\t\t\t\t\t
                              """
                            4 => """
                              A Khan \n
                              \t\t\t\t\t\t\t\t
                              """
                            5 => """
                              R Akhter \n
                              \t\t\t\t\t\t\t\t
                              """
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Coll Physicians Surg Pak"
                        "fecha" => "2005"
                        "volumen" => "15"
                        "paginaInicial" => "234"
                        "paginaFinal" => "237"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15857598"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib5"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Tuberculosis of the breast masquerading as carcinoma&#58; a study of 100 patients"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => """
                              SR Shinde \n
                              \t\t\t\t\t\t\t\t
                              """
                            1 => """
                              RY Chandawarkar \n
                              \t\t\t\t\t\t\t\t
                              """
                            2 => """
                              SP Deshmukh \n
                              \t\t\t\t\t\t\t\t
                              """
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/BF00299163"
                      "Revista" => array:6 [
                        "tituloSerie" => "World J Surg"
                        "fecha" => "1995"
                        "volumen" => "19"
                        "paginaInicial" => "379"
                        "paginaFinal" => "381"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7638992"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib6"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "Cooper A&#46; Illustrations of the Diseases of the Breast&#44; Part1 London&#44; Longman&#44; Rees&#44; Orme&#44; Brown and Green&#46;1829&#46; p&#46; 73&#46;"
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib7"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Breast Tuberculosis&#58; Still Common In India"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => """
                              Puneet \n
                              \t\t\t\t\t\t\t\t
                              """
                            1 => """
                              K Satyendra \n
                              \t\t\t\t\t\t\t\t
                              """
                            2 => """
                              Tiwary \n
                              \t\t\t\t\t\t\t\t
                              """
                            3 => """
                              Ritu Ragini \n
                              \t\t\t\t\t\t\t\t
                              """
                            4 => """
                              Sanjay Singh \n
                              \t\t\t\t\t\t\t\t
                              """
                            5 => """
                              SK Gupta \n
                              \t\t\t\t\t\t\t\t
                              """
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:2 [
                    0 => array:1 [
                      "Revista" => array:4 [
                        "tituloSerie" => "The Internet Journal of Tropical Medicine"
                        "fecha" => "2005"
                        "volumen" => "2"
                        "paginaInicial" => "2"
                      ]
                    ]
                    1 => array:1 [
                      "WWW" => array:1 [
                        "link" => "http&#58;&#47;&#47;www&#46;ispub&#46;com&#47;ostia&#47;index&#46;php&#63;xmlFilePath&#61;journals&#47;ijtm&#47;vol2n2&#47;breast&#46;xml"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            7 => array:3 [
              "identificador" => "bib8"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Tuberculosis of breast"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => """
                              GP Kedar \n
                              \t\t\t\t\t\t\t\t
                              """
                            1 => """
                              SK Bophate \n
                              \t\t\t\t\t\t\t\t
                              """
                            2 => """
                              M Kherdekar \n
                              \t\t\t\t\t\t\t\t
                              """
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:4 [
                        "tituloSerie" => "Ind J Tub"
                        "fecha" => "1985"
                        "volumen" => "32"
                        "paginaInicial" => "146"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            8 => array:3 [
              "identificador" => "bib9"
              "etiqueta" => "9"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Granulomatous mammary disease&#58; ten years&#8217; experience with fine needle aspiration cytology"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => """
                              KE Elsiddig \n
                              \t\t\t\t\t\t\t\t
                              """
                            1 => """
                              EA Khalil \n
                              \t\t\t\t\t\t\t\t
                              """
                            2 => """
                              IA Elhag \n
                              \t\t\t\t\t\t\t\t
                              """
                            3 => """
                              ME Elsafi \n
                              \t\t\t\t\t\t\t\t
                              """
                            4 => """
                              GM Suleiman \n
                              \t\t\t\t\t\t\t\t
                              """
                            5 => """
                              IM Elkhidir \n
                              \t\t\t\t\t\t\t\t
                              """
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Int J Tuberc Lung Dis"
                        "fecha" => "2003"
                        "volumen" => "7"
                        "paginaInicial" => "365"
                        "paginaFinal" => "369"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12729342"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            9 => array:3 [
              "identificador" => "bib10"
              "etiqueta" => "10"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The diagnosis and treatment of tuberculosis of the breast"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => """
                              TS Wilson \n
                              \t\t\t\t\t\t\t\t
                              """
                            1 => """
                              JW Macgregor \n
                              \t\t\t\t\t\t\t\t
                              """
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Can Med Assoc J"
                        "fecha" => "1963"
                        "volumen" => "89"
                        "paginaInicial" => "1118"
                        "paginaFinal" => "1124"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/14079137"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            10 => array:3 [
              "identificador" => "bib11"
              "etiqueta" => "11"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Tuberculosis of breast- a retrospective review of cases"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => """
                              KD Pal \n
                              \t\t\t\t\t\t\t\t
                              """
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Ind J Tub"
                        "fecha" => "1998"
                        "volumen" => "45"
                        "paginaInicial" => "35"
                        "paginaFinal" => "37"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            11 => array:3 [
              "identificador" => "bib12"
              "etiqueta" => "12"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Tuberculosis of breast &#40;study of 7 cases&#41;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => """
                              PK Sharma \n
                              \t\t\t\t\t\t\t\t
                              """
                            1 => """
                              AL Babel \n
                              \t\t\t\t\t\t\t\t
                              """
                            2 => """
                              SS Yadav \n
                              \t\t\t\t\t\t\t\t
                              """
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Postgrad Med"
                        "fecha" => "1991"
                        "volumen" => "37"
                        "paginaInicial" => "24"
                        "paginaFinal" => "26A"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/1941687"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            12 => array:3 [
              "identificador" => "bib13"
              "etiqueta" => "13"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Mammary tuberculosis&#58; report on 52 cases"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => """
                              R Khanna \n
                              \t\t\t\t\t\t\t\t
                              """
                            1 => """
                              GV Prasanna \n
                              \t\t\t\t\t\t\t\t
                              """
                            2 => """
                              P Gupta \n
                              \t\t\t\t\t\t\t\t
                              """
                            3 => """
                              M Kumar \n
                              \t\t\t\t\t\t\t\t
                              """
                            4 => """
                              S Khanna \n
                              \t\t\t\t\t\t\t\t
                              """
                            5 => """
                              AK Khanna \n
                              \t\t\t\t\t\t\t\t
                              """
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1136/pmj.78.921.422"
                      "Revista" => array:6 [
                        "tituloSerie" => "Postgrad Med J"
                        "fecha" => "2002"
                        "volumen" => "78"
                        "paginaInicial" => "422"
                        "paginaFinal" => "424"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12151660"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            13 => array:3 [
              "identificador" => "bib14"
              "etiqueta" => "14"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Bacteriology or Pathology for tuberculous mastitis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => """
                              D Ozol \n
                              \t\t\t\t\t\t\t\t
                              """
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Int J Tuberc Lung Dis"
                        "fecha" => "2006"
                        "volumen" => "10"
                        "paginaInicial" => "824"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16850548"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            14 => array:3 [
              "identificador" => "bib15"
              "etiqueta" => "15"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Tuberculous mastitis&#58; a disease not to be forgotten"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => """
                              KE Bani-Hani \n
                              \t\t\t\t\t\t\t\t
                              """
                            1 => """
                              RJ Yaghan \n
                              \t\t\t\t\t\t\t\t
                              """
                            2 => """
                              II Matalka \n
                              \t\t\t\t\t\t\t\t
                              """
                            3 => """
                              TS Mazahreh \n
                              \t\t\t\t\t\t\t\t
                              """
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Int J Tuberc Lung Dis"
                        "fecha" => "2005"
                        "volumen" => "9"
                        "paginaInicial" => "920"
                        "paginaFinal" => "925"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16104641"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            15 => array:3 [
              "identificador" => "bib16"
              "etiqueta" => "16"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Improved diagnostic evaluation of suspected tuberculosis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => """
                              DP Dosanjh \n
                              \t\t\t\t\t\t\t\t
                              """
                            1 => """
                              TS Hinks \n
                              \t\t\t\t\t\t\t\t
                              """
                            2 => """
                              JA Innes \n
                              \t\t\t\t\t\t\t\t
                              """
                            3 => """
                              JJ Deeks \n
                              \t\t\t\t\t\t\t\t
                              """
                            4 => """
                              G Pasvol \n
                              \t\t\t\t\t\t\t\t
                              """
                            5 => """
                              S Hackforth \n
                              \t\t\t\t\t\t\t\t
                              """
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.7326/0003-4819-148-5-200803040-00003"
                      "Revista" => array:6 [
                        "tituloSerie" => "Ann Intern Med"
                        "fecha" => "2008"
                        "volumen" => "148"
                        "paginaInicial" => "325"
                        "paginaFinal" => "336"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18316751"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            16 => array:3 [
              "identificador" => "bib17"
              "etiqueta" => "17"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Tuberculosis of the Breast"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => """
                              E Goksoy \n
                              \t\t\t\t\t\t\t\t
                              """
                            1 => """
                              M Duren \n
                              \t\t\t\t\t\t\t\t
                              """
                            2 => """
                              V Durgun \n
                              \t\t\t\t\t\t\t\t
                              """
                            3 => """
                              N Uygun \n
                              \t\t\t\t\t\t\t\t
                              """
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur J Surg"
                        "fecha" => "1995"
                        "volumen" => "161"
                        "paginaInicial" => "471"
                        "paginaFinal" => "473"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7488659"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            17 => array:3 [
              "identificador" => "bib18"
              "etiqueta" => "18"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Breast tuberculosis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => """
                              D Ozol \n
                              \t\t\t\t\t\t\t\t
                              """
                            1 => """
                              M Bozer \n
                              \t\t\t\t\t\t\t\t
                              """
                            2 => """
                              R Bayrak \n
                              \t\t\t\t\t\t\t\t
                              """
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Saudi Med J"
                        "fecha" => "2006"
                        "volumen" => "27"
                        "paginaInicial" => "1066"
                        "paginaFinal" => "1068"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16830034"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            18 => array:3 [
              "identificador" => "bib19"
              "etiqueta" => "19"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Mammography features of isolated tuberculous mastitis"
                      "autores" => array:1 [
                        0 => array:2 [
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Article information
ISSN: 18075932
Original language: English
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos