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Tubercular cervicitis: a rare presentation of disseminated tuberculosis
G Model INJMS 139 No. of Pages 3
Indian Journal of Medical Specialities xxx (2017) xxx–xxx
Contents lists available at ScienceDirect
Indian Journal of Medical Specialities journal homepage: www.elsevier.com/locate/injms
Case report
Tubercular cervicitis: a rare presentation of disseminated tuberculosis Aruna Nigama,* ,1, Zeeba S. Jairajpuric,1, Abhinav Jainb,1, Chanda Raia,1 a
Department of Obstetrics and Gynaecology, India Department of Raadiology, India c Department of Pathology, India b
A R T I C L E I N F O
Article history: Received 20 May 2017 Accepted 30 June 2017 Available online xxx Keywords: Cervix Tuberculosis Colposcopy
A B S T R A C T
Tuberculosis is a major health problem in India. The tubercular infection may flare up in pregnancy and postpartum period due to the altered immune status of the female. The presentation may be varied in this condition. A case of disseminated tuberculosis presenting as irregular vaginal bleeding and cervical growth mimicking as malignancy in the postpartum female is reported. © 2017 Published by Elsevier, a division of RELX India, Pvt. Ltd on behalf of Indian Journal of Medical Specialities.
1. Introduction Disseminated tuberculosis is defined as two or more contiguous sites having tuberculous infection resulting from lymphohematogenous dissemination of Mycobacterium tuberculosis [1]. It is more common in patients with HIV infection where the immunity is low. A case of disseminated tuberculosis presenting as irregular vaginal bleeding and cervical growth in the postpartum female is reported. 2. Case report A 24 years para four female presented with complaint of irregular vaginal bleeding for the last one and a half months. She had delivered one and a half months back and was not breast feeding her child. She also gave history of loss of appetite and weight loss. Although there was no history of coitus in last five months, there was no history of postcoital bleeding before that. There was no history of fever, cough or abdominal pain. On general examination, she was 152 cm tall with 38.5 kg weight (BMI = 16.66)) with mild anemia. Systemic examination was unremarkable. Speculum examination showed a growth on the anterior lip of cervix and on the anterior wall of vagina which bled on touch. The cervical lips could not be delineated clearly.
* Corresponding author at: Flat No 6, Type 4 Quarters, Lady Hardinge Medical College Campus, Shaheed Bhagat Singh marg, New Delhi 110001, India. E-mail address: [email protected] (A. Nigam). 1 All authors are affiliated to and study done at: Hamdard Institute of Medical Sciences and Research, Jamia Hamdard, New Delhi 110001, India.
Pelvic examination revealed a normal sized uterus with no tenderness and no adnexal mass. Rectum examination was unremarkable. A clinical suspicion of cervical malignancy was entertained. Colposcopy was done and biopsy of the cervical growth was taken. Colposcopy (Fig. 1) showed grade 3 acetowhiteness with irregular vascular pattern in the lesion. Her hemoglobin was 9.5 gm% with raised ESR (46 mm). Her sputum for acid fast bacilli was positive. Her abdominal ultrasound detected multiple prominent peripheral vessels in myometrium without any obvious mass and multiple enlarged contiguous lymph nodes with areas of necrosis were seen in retro-peritoneum (Fig. 2). Her chest X-ray showed opacity in right upper zone with patchy, inhomogeneous opacity in left upper and mid-zone. The histopathology of the cervical biopsy (Figs. 3 and 4) revealed necrotizing granulomatous lesion of the cervix. The lining stratified squamous epithelium of cervix was found to be unremarkable but the endocervical glands with intervening stroma showed numerous epithelioid cell granulomas, Langhans giant cells and areas of necrosis. There was no evidence of atypia or dysplasia. Endometrial biopsy was positive for Ziehl-Neelsen staining of acid fast bacillus. A diagnosis of disseminated tuberculosis was made based on endometrial and sputum culture report as well as cervical biopsy report and ultrasound and chest Xray findings. Patient was started on 4 drug (rifampicin, isoniazid, ethambutol, pyrazinamide) anti-tubercular therapy. After two month of starting the antitubercular treatment, colposcopic examination found the cervix to have improved with the disappearance of growth and the cervical lips were well delineated (Fig. 5). Patient is still in follow-up and her general condition has
http://dx.doi.org/10.1016/j.injms.2017.06.006 0976-2884/© 2017 Published by Elsevier, a division of RELX India, Pvt. Ltd on behalf of Indian Journal of Medical Specialities.
Please cite this article in press as: A. Nigam, et al., Tubercular cervicitis: a rare presentation of disseminated tuberculosis, Indian J Med Spec. (2017), http://dx.doi.org/10.1016/j.injms.2017.06.006
G Model INJMS 139 No. of Pages 3
2
A. Nigam et al. / Indian Journal of Medical Specialities xxx (2017) xxx–xxx
Fig. 1. Colposcopic picture showing grade 3 acetowhiteness on the cervical lesion.
Fig. 4. High power microphotograph shows numerous epithelioid cell (arrows) along with necrosis and giant cell. H&E, 40X.
Fig. 2. Ultrasound of the abdomen showing the enlarged contiguous lymph nodes in the retroperitoneum (white arrows).
Fig. 5. Colposcopic picture of the healthy cervix after 2 months of antitubercular treatment.
improved. Husband has also been diagnosed as a case of pulmonary tuberculosis and is under treatment. 3. Discussion
Fig. 3. Photomicrograph of the cervix shows epithelioid cell granulomas with numerous Langhan’s Giant cells (Black arrows) along with endocervical lining (blue arrow), H&E, 10X.
Tuberculosis is still a major health problem in India and contributes to 20% of global burden of tuberculosis [2]. Tuberculosis can affect any organ in the body and can exist without any manifestations for years. The presentation in pregnancy and postpartum period can vary because of varied nutritional and immune status of the mother. Cervical tuberculosis is a rare entity and accounts for 0.1–0.65% of all cases of tuberculosis and consists of 5–24% cases of genital tuberculosis [3]. It usually occurs secondary to primary focus elsewhere in the body due to direct spread or by miliary seeding via blood or lymphatics as occurred in this case. In 8% cases it can be primary cervical tuberculosis and is usually introduced by the sexual partner suffering from tubercular epididymitis or other genitourinary tuberculosis or when sputum is used as sexual lubricant [4]. Cervix is relatively resistant to tuberculous infection because of its histological structure. The stratified squamous epithelium of the ectocervix prevents bacterial penetration and endocervical mucus acts as protective barrier. Dislodgement of bacteria due to
Please cite this article in press as: A. Nigam, et al., Tubercular cervicitis: a rare presentation of disseminated tuberculosis, Indian J Med Spec. (2017), http://dx.doi.org/10.1016/j.injms.2017.06.006
G Model INJMS 139 No. of Pages 3
A. Nigam et al. / Indian Journal of Medical Specialities xxx (2017) xxx–xxx
the monthly endometrial shedding also limits exposure to the mycobacteria. In presence of lowered immunity as in cases of malnourishment, HIV infection or during pregnancy and puerperium, the tubercular infection may flare up as probably occurred in this case. 50% of cervical tuberculosis cases remain asymptomatic. In 90% of symptomatic cases the cervix may appear normal, but in rest of the cases it may present as hypertrophic or ulcerative lesion or as fistulas or sinuses. In hypertrophied cervix, bacterial multiplication is minimal and due to strong immune response, histological feature shows pseudoepitheliomatous hyperplasia of squamous epithelium of cervix with ill-defined caseous tubercles and many times acid fast bacilli culture is negative. In ulcerative lesions, histological feature shows well-formed tubercles and caseous necrosis with more numbers of mycobacteria. In presence of granuloma on histpathology, the differential diagnosis should include lymphogranuloma venereum, sarcoidosis, syphilis, granuloma inguinale, schistosomiasis or foreign body reaction. Isolation of tubercular bacilli is gold standard for the final diagnosis of cervical tuberculosis but in one-third of cases, the culture may be negative [5,6]. As the appearance of cervical tuberculosis may mimic cervical malignancy, as was clinically suspected in this case, careful examination of the biopsy specimens is mandatory as cervical tuberculosis and cervical carcinoma may coexist [7]. Examination of all the organs is recommended in cases of cervical tuberculosis as primary cervical tuberculosis is a very rare condition and patient may be harbouring the infection elsewhere also as in this case. The examination of the sexual partner as well as other family members is also necessary especially in cases of untreated and disseminated tuberculosis cases as in this case.
3
4. Conclusion A young woman presenting with irregular vaginal bleeding along with a cervical growth should always raise the suspicion of tuberculosis especially in the endemic areas, in addition to a differential of malignancy. Screening of the family members of the index case must be done in order to provide the treatment at the right time. Conflict of interest None. References [1] Ayaslioglu Basar H, Duruyurek N, Kapaklioglu F, Gocmen S, Erturk A, Yilmaz S. Disseminated tuberculosis with lymphatic, splenic and scrotal abscesses: a Case report. Caes J 2009;2:6995 PMID:19918502. [2] Prakash A. Tuberculosis: the scourge of mankind. IJMS 2012;3:19–22. [3] Sabita S, Sharmila V, Arun Babu T, Sinhasan SP, Darendra S. A rare case of cervical tuberculosis which simulated carcinoma of the cervix. J Clin Diagn res 2013;7:1189–90 PMID: 23905138. [4] Kalyani R, Sheela SR, Rajini M. Cytological diagnosis of tubercular cervicitis: a case report with review of literature. J Cytol 2012;29:86–8 PMID: 22438630. [5] Lamba H, Byrne M, Goldin R, Jenkins C. Tuberculosis of the cervix: Case presentation and a review of the literature. Sex Transm Infect 2002;78:62–3 PMID: 11872864. [6] Wadhwa N, Singh UR, Saith S. A report of two unsuspected cases of cervical tuberculosis. Indian J Pathol Microbiol 2005;3:390–2 PMID: 16761765. [7] Samantaray S, Parida G, Rout N, Giri SK, Kar R. Cytologic detection of tuberculous cervicitis. Acta Cytol 2009;5:594–6 PMID: 19798892.
Please cite this article in press as: A. Nigam, et al., Tubercular cervicitis: a rare presentation of disseminated tuberculosis, Indian J Med Spec. (2017), http://dx.doi.org/10.1016/j.injms.2017.06.006
Indian Journal of Medical Specialities xxx (2017) xxx–xxx
Contents lists available at ScienceDirect
Indian Journal of Medical Specialities journal homepage: www.elsevier.com/locate/injms
Case report
Tubercular cervicitis: a rare presentation of disseminated tuberculosis Aruna Nigama,* ,1, Zeeba S. Jairajpuric,1, Abhinav Jainb,1, Chanda Raia,1 a
Department of Obstetrics and Gynaecology, India Department of Raadiology, India c Department of Pathology, India b
A R T I C L E I N F O
Article history: Received 20 May 2017 Accepted 30 June 2017 Available online xxx Keywords: Cervix Tuberculosis Colposcopy
A B S T R A C T
Tuberculosis is a major health problem in India. The tubercular infection may flare up in pregnancy and postpartum period due to the altered immune status of the female. The presentation may be varied in this condition. A case of disseminated tuberculosis presenting as irregular vaginal bleeding and cervical growth mimicking as malignancy in the postpartum female is reported. © 2017 Published by Elsevier, a division of RELX India, Pvt. Ltd on behalf of Indian Journal of Medical Specialities.
1. Introduction Disseminated tuberculosis is defined as two or more contiguous sites having tuberculous infection resulting from lymphohematogenous dissemination of Mycobacterium tuberculosis [1]. It is more common in patients with HIV infection where the immunity is low. A case of disseminated tuberculosis presenting as irregular vaginal bleeding and cervical growth in the postpartum female is reported. 2. Case report A 24 years para four female presented with complaint of irregular vaginal bleeding for the last one and a half months. She had delivered one and a half months back and was not breast feeding her child. She also gave history of loss of appetite and weight loss. Although there was no history of coitus in last five months, there was no history of postcoital bleeding before that. There was no history of fever, cough or abdominal pain. On general examination, she was 152 cm tall with 38.5 kg weight (BMI = 16.66)) with mild anemia. Systemic examination was unremarkable. Speculum examination showed a growth on the anterior lip of cervix and on the anterior wall of vagina which bled on touch. The cervical lips could not be delineated clearly.
* Corresponding author at: Flat No 6, Type 4 Quarters, Lady Hardinge Medical College Campus, Shaheed Bhagat Singh marg, New Delhi 110001, India. E-mail address: [email protected] (A. Nigam). 1 All authors are affiliated to and study done at: Hamdard Institute of Medical Sciences and Research, Jamia Hamdard, New Delhi 110001, India.
Pelvic examination revealed a normal sized uterus with no tenderness and no adnexal mass. Rectum examination was unremarkable. A clinical suspicion of cervical malignancy was entertained. Colposcopy was done and biopsy of the cervical growth was taken. Colposcopy (Fig. 1) showed grade 3 acetowhiteness with irregular vascular pattern in the lesion. Her hemoglobin was 9.5 gm% with raised ESR (46 mm). Her sputum for acid fast bacilli was positive. Her abdominal ultrasound detected multiple prominent peripheral vessels in myometrium without any obvious mass and multiple enlarged contiguous lymph nodes with areas of necrosis were seen in retro-peritoneum (Fig. 2). Her chest X-ray showed opacity in right upper zone with patchy, inhomogeneous opacity in left upper and mid-zone. The histopathology of the cervical biopsy (Figs. 3 and 4) revealed necrotizing granulomatous lesion of the cervix. The lining stratified squamous epithelium of cervix was found to be unremarkable but the endocervical glands with intervening stroma showed numerous epithelioid cell granulomas, Langhans giant cells and areas of necrosis. There was no evidence of atypia or dysplasia. Endometrial biopsy was positive for Ziehl-Neelsen staining of acid fast bacillus. A diagnosis of disseminated tuberculosis was made based on endometrial and sputum culture report as well as cervical biopsy report and ultrasound and chest Xray findings. Patient was started on 4 drug (rifampicin, isoniazid, ethambutol, pyrazinamide) anti-tubercular therapy. After two month of starting the antitubercular treatment, colposcopic examination found the cervix to have improved with the disappearance of growth and the cervical lips were well delineated (Fig. 5). Patient is still in follow-up and her general condition has
http://dx.doi.org/10.1016/j.injms.2017.06.006 0976-2884/© 2017 Published by Elsevier, a division of RELX India, Pvt. Ltd on behalf of Indian Journal of Medical Specialities.
Please cite this article in press as: A. Nigam, et al., Tubercular cervicitis: a rare presentation of disseminated tuberculosis, Indian J Med Spec. (2017), http://dx.doi.org/10.1016/j.injms.2017.06.006
G Model INJMS 139 No. of Pages 3
2
A. Nigam et al. / Indian Journal of Medical Specialities xxx (2017) xxx–xxx
Fig. 1. Colposcopic picture showing grade 3 acetowhiteness on the cervical lesion.
Fig. 4. High power microphotograph shows numerous epithelioid cell (arrows) along with necrosis and giant cell. H&E, 40X.
Fig. 2. Ultrasound of the abdomen showing the enlarged contiguous lymph nodes in the retroperitoneum (white arrows).
Fig. 5. Colposcopic picture of the healthy cervix after 2 months of antitubercular treatment.
improved. Husband has also been diagnosed as a case of pulmonary tuberculosis and is under treatment. 3. Discussion
Fig. 3. Photomicrograph of the cervix shows epithelioid cell granulomas with numerous Langhan’s Giant cells (Black arrows) along with endocervical lining (blue arrow), H&E, 10X.
Tuberculosis is still a major health problem in India and contributes to 20% of global burden of tuberculosis [2]. Tuberculosis can affect any organ in the body and can exist without any manifestations for years. The presentation in pregnancy and postpartum period can vary because of varied nutritional and immune status of the mother. Cervical tuberculosis is a rare entity and accounts for 0.1–0.65% of all cases of tuberculosis and consists of 5–24% cases of genital tuberculosis [3]. It usually occurs secondary to primary focus elsewhere in the body due to direct spread or by miliary seeding via blood or lymphatics as occurred in this case. In 8% cases it can be primary cervical tuberculosis and is usually introduced by the sexual partner suffering from tubercular epididymitis or other genitourinary tuberculosis or when sputum is used as sexual lubricant [4]. Cervix is relatively resistant to tuberculous infection because of its histological structure. The stratified squamous epithelium of the ectocervix prevents bacterial penetration and endocervical mucus acts as protective barrier. Dislodgement of bacteria due to
Please cite this article in press as: A. Nigam, et al., Tubercular cervicitis: a rare presentation of disseminated tuberculosis, Indian J Med Spec. (2017), http://dx.doi.org/10.1016/j.injms.2017.06.006
G Model INJMS 139 No. of Pages 3
A. Nigam et al. / Indian Journal of Medical Specialities xxx (2017) xxx–xxx
the monthly endometrial shedding also limits exposure to the mycobacteria. In presence of lowered immunity as in cases of malnourishment, HIV infection or during pregnancy and puerperium, the tubercular infection may flare up as probably occurred in this case. 50% of cervical tuberculosis cases remain asymptomatic. In 90% of symptomatic cases the cervix may appear normal, but in rest of the cases it may present as hypertrophic or ulcerative lesion or as fistulas or sinuses. In hypertrophied cervix, bacterial multiplication is minimal and due to strong immune response, histological feature shows pseudoepitheliomatous hyperplasia of squamous epithelium of cervix with ill-defined caseous tubercles and many times acid fast bacilli culture is negative. In ulcerative lesions, histological feature shows well-formed tubercles and caseous necrosis with more numbers of mycobacteria. In presence of granuloma on histpathology, the differential diagnosis should include lymphogranuloma venereum, sarcoidosis, syphilis, granuloma inguinale, schistosomiasis or foreign body reaction. Isolation of tubercular bacilli is gold standard for the final diagnosis of cervical tuberculosis but in one-third of cases, the culture may be negative [5,6]. As the appearance of cervical tuberculosis may mimic cervical malignancy, as was clinically suspected in this case, careful examination of the biopsy specimens is mandatory as cervical tuberculosis and cervical carcinoma may coexist [7]. Examination of all the organs is recommended in cases of cervical tuberculosis as primary cervical tuberculosis is a very rare condition and patient may be harbouring the infection elsewhere also as in this case. The examination of the sexual partner as well as other family members is also necessary especially in cases of untreated and disseminated tuberculosis cases as in this case.
3
4. Conclusion A young woman presenting with irregular vaginal bleeding along with a cervical growth should always raise the suspicion of tuberculosis especially in the endemic areas, in addition to a differential of malignancy. Screening of the family members of the index case must be done in order to provide the treatment at the right time. Conflict of interest None. References [1] Ayaslioglu Basar H, Duruyurek N, Kapaklioglu F, Gocmen S, Erturk A, Yilmaz S. Disseminated tuberculosis with lymphatic, splenic and scrotal abscesses: a Case report. Caes J 2009;2:6995 PMID:19918502. [2] Prakash A. Tuberculosis: the scourge of mankind. IJMS 2012;3:19–22. [3] Sabita S, Sharmila V, Arun Babu T, Sinhasan SP, Darendra S. A rare case of cervical tuberculosis which simulated carcinoma of the cervix. J Clin Diagn res 2013;7:1189–90 PMID: 23905138. [4] Kalyani R, Sheela SR, Rajini M. Cytological diagnosis of tubercular cervicitis: a case report with review of literature. J Cytol 2012;29:86–8 PMID: 22438630. [5] Lamba H, Byrne M, Goldin R, Jenkins C. Tuberculosis of the cervix: Case presentation and a review of the literature. Sex Transm Infect 2002;78:62–3 PMID: 11872864. [6] Wadhwa N, Singh UR, Saith S. A report of two unsuspected cases of cervical tuberculosis. Indian J Pathol Microbiol 2005;3:390–2 PMID: 16761765. [7] Samantaray S, Parida G, Rout N, Giri SK, Kar R. Cytologic detection of tuberculous cervicitis. Acta Cytol 2009;5:594–6 PMID: 19798892.
Please cite this article in press as: A. Nigam, et al., Tubercular cervicitis: a rare presentation of disseminated tuberculosis, Indian J Med Spec. (2017), http://dx.doi.org/10.1016/j.injms.2017.06.006