Breast tuberculosis is a rare extrapulmonary manifestation of Mycobacterium tuberculosis, representing less than 0.1% of all breast pathologies in developed countries. However, in regions with high tuberculosis prevalence, such as India and Africa, its incidence is higher. The disease poses diagnostic challenges due to its ability to mimic breast carcinoma, leading to potential misdiagnosis and unnecessary surgical interventions. This study investigates the clinical and imaging characteristics of breast tuberculosis in a large cohort, with a specific focus on a rare case in a postmenopausal woman. A retrospective observational study was conducted on 1704 women who presented for mammography at the Alessandrescu-Rusescu National Institute for Mother and Child Health between 2019 and 2021. Clinical presentation, imaging results, and histopathological findings were analyzed to identify cases of breast tuberculosis. The study includes a comparative analysis with other granulomatous diseases and malignant breast conditions to highlight key diagnostic features. Among the 1704 patients, 714 (41.9%) presented with symptoms such as pain (35.4%), palpable lumps (13.2%), nipple discharge (4.3%), and breast appearance changes (2.1%). A rare case of primary breast tuberculosis was identified in a 69-year-old postmenopausal woman, presenting with a painless, palpable mass in the upper outer quadrant. Imaging demonstrated a hypoechoic mass with fine granular content and posterior acoustic enhancement, categorized as BIRADS 4A. The biopsy confirmed the diagnosis of breast tuberculosis. This study underscores the diagnostic complexity of breast tuberculosis, particularly in its ability to mimic malignancy. Through detailed imaging and clinical analysis, we emphasize the importance of biopsy in differentiating tuberculosis from breast cancer. Given the potential for misdiagnosis, clinicians should consider breast tuberculosis in differential diagnoses, especially in regions with high tuberculosis prevalence. Further research is needed to develop specific imaging criteria for earlier and more accurate diagnosis.