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Primary tuberculosis of the cervix uteri
PRIMARY
TUBERCULOSIS OF THE CERVIX UTERI*
BENJAMIN RICE SHORE, M.D. AND CONDICT MOORE, M.D. New York, New York
RIMARY tubercuIosis of the cervix uteri is difficult or impossibIe to prove. In several reported cases’” histologic examination of the tubes, ovaries and fundus of the uterus removed with or subsequent to the cervical Iesion faiIed to revear tubercuIosis and in these instances the tubercuIous infection of the cervix may be considered to be primary. In the case we are reporting histoIogic study of the uterus and faIIopian tubes re-
P
moved five years previousIy did not revea1 tuberculosis, and roentgenograms of the chest show no evidence of past or present puImonary tubercuIous infection. In addi-
tion to being a primary case this is the onIy reported one, to our knowIedge, in which tubercuIosis of a retained cervix has been observed several years folIowing hysterectomy and bilatera1 saIpingo-oophorectomy for non-tubercuIous lesions. CASE
REPORT
A thirty-four year old femaIe was first admitted to St. Luke’s HospitaI on January 26, 1926, complaining of a tumor in the lower abdomen and dysmenorrhea. She had one child seven years old but had had no other pregnancies. Nothing eIse of importance was elicited in the history. PeIvic examination showed the cervix to be smah, hard and directed downward whiIe the uterine body was pushed to the Ieft by a firm, fixed mass in the right fornix. The bIood Wassermann was negative. The diagnosis of chronic salpingitis was made and Iaparotomy was performed. Both fallopian tubes were indurated, swoIIen, kinked and distorted by adhesions. The uterus was small and was bound to the adnexae by firm adhesions. Supravaginal hysterectomy and bilateral salpingo-oophorectomy were performed. The patient made an uneventful recovery except for a mild pyeIitis and she was discharged from the hospital with a we11 * From Surgical Division August,
1949
healed wound on the nineteenth postoperative day. PathologicaIIy, the specimen consisted of the body of the uterus and both tubes and ovaries. The fundus of the uterus was covered by shaggy adhesions. The cavity was smaI1 and the muscIe and mucosa were somewhat hypertrophied. Both tubes and ovaries were edematous and eIongated. HistoIogic study of the endometrium showed hyperpIasia and evidences of chronic infection, the stroma being moderateIy infiItrated and the increased, gIands diIated and fiIIed with secretion. The uterine muscIe was aIso slightly infiItrated and edematous. The tubes showed a Iate stage of chronic pyogenic suppuration; the Iumina were ditated and the mucosa was very much hypertrophied and infiItrated throughout with Iarge numbers of Iymphocytes and pIasma ceIIs. There was no evidence of tuberculosis. The diagnosis was chronic endometritis and chronic saIpingo-oophoritis. The patient was re-admitted to St. Luke’s HospitaI on September 20, 1931, CompIaining of a thin, watery vagina1 discharge of ten weeks duration. Several times there had been sIight bleeding but during the two weeks prior to her admission there had been more constant bleeding without hemorrhages. She had Iost 4 or 6 pounds in weight. Careful questioning failed to revea1 any past or present tubercuIosis in any member of her family and knowledge of genita1 tubercuIosis in her husband, from whom she is now separated, was denied. The patient was a we11 developed and we11 nourished negro. Except for the IocaI pelvic condition no other physica abnormaIities couId be made out. The bIood Wassermann was negative. X-rays of the chest were essentiaIIy normal. PeIvic examination showed a firm perineum which gave good support. The uterine body was missing and the vaults were shortened. The cervix was irregular and hard. On the posterior Iip there was a smaI1, friable, bIeeding, fungating mass which extended upward on to the vagina1 waI1 toward the Ieft
B and the PathoIogicaI Laboratory
273
of St. Luke’s HospitaI, New York, N. Y.
274
Shore,
Moore-Tuberculosis
of
Cervix
Uteri
smooth, completeIy heaIed over and showed The no evidence of residua1 tubercuIosis.
patient was seen at reguIar intervaIs and remained we11 until 1940 when, because of bIeedof the cervix was ing, a benign papiIIoma removed in the out-patient department. HistoIogic study of this benign tumor showed no evidence’ of tubercuIosis. BIeeding ceased following remova of this poIyp and the patient was symptom-free until May, 1943, when vagina1 bIeeding recurred and the patient Iost 15 pounds in weight. Sharp curettage of the cervix yieIded typica tubercuIous granuIation tissue. No other treatment was given and when she was Iast seen on September 3, 1947, sixteen years after primary treatment for the tubercuIous cervix, the patient was we11 and free from symptoms. Examination at this time discIosed hyperemia of the vagina1 mucous membrane but no ulcers or granuIating areas. Histologic study of a smaI1 portion of this reddened epitheIium showed onIy chronic vaginitis with no evidence of tubercuIosis. SUMMARY
FIG. 1. Photomicrograph cuIous lesion.
of primary
cervical
tuber-
broad Iigament. CIinicaIly the Iesion was thought to be a carcinoma. Under genera1 anesthesia a biopsy was taken for histoIogic study. Four, IO mg. radium needIes were inserted directIy into the Iesion and packed in place with two strips of iodoform gauze. This radium remained in pIace for forty-eight hours, giving a tota dose of 1,920 mg. hours. HistoIogic study of the biopsy specimen removed from the cervix uteri showed a portion of the squamous epithelium which was hypertrophied to a very unusua1 degree. The undedying fibrous stroma was converted into a mass of tubercuIous tissue. There were confluent and discreet tubercIes with many Langhans’ giant ceIIs, endotheIia1 ceIIs and Iymphocytes. The diagnosis of tuberculosis of the cervix uteri was made. (Fig. I .) The patient was discharged from the hospita1 on her sixth postoperative day. At her first follow-up visit on January 26, 1932, four months after the radium treatment, she was entirely free from symptoms. The cervix was
A patient with tubercuIosis of the uterine cervix, which occurred five years foIIowing supravaginal amputation of the uterus and biIatera1 saIpingo-oophorectomy for non-tubercuIous Iesions, is alive and symptom-free sixteen years foIIowing the initia1 treatment with radium. This is the onIy reported case, to our knowIedge, in which tuberculosis of a retained cervix has been observed severa years after hysterectomy and biIatera1 saIpingo-oophorectomy for non-tubercuIous Iesions. REFERENCES
of the cervix. Am. J. Obst. t? Gynec., 20: 24~25 I, 1930. 2. ENNIO, BORTONI. Di un case di tubercolosi primitiva Iocalizzata aI canale cervicale. Ann. di ostet. e gmec., 52: 112o-1135, 1930. 3. LANTEJOUL, P. Un cas de tuberculose genitale chez Ia femme. Bull. Sot. gyntc. et d’obst., 2 I : 432-433, I. HARRIS, B. A. TubercuIosis
1932. 4. DANNREUTHER, W. T. Discussion of a paper by B. P. Watson, TubercuIosis of the cervix uteri. Am. J. Obst. u Gynec., 27: 739. 1934. 4. TASCHE, J. Primarv tuberculosis of the cervix-a case’report. Wisconsin M. J., 39: 526527, 1940. 6. DENTON, J. F. TubercuIosis of the cervix. J. M. A. Georgia, 33: 37-40, 1944.
American
Journal
of Surgery
TUBERCULOSIS OF THE CERVIX UTERI*
BENJAMIN RICE SHORE, M.D. AND CONDICT MOORE, M.D. New York, New York
RIMARY tubercuIosis of the cervix uteri is difficult or impossibIe to prove. In several reported cases’” histologic examination of the tubes, ovaries and fundus of the uterus removed with or subsequent to the cervical Iesion faiIed to revear tubercuIosis and in these instances the tubercuIous infection of the cervix may be considered to be primary. In the case we are reporting histoIogic study of the uterus and faIIopian tubes re-
P
moved five years previousIy did not revea1 tuberculosis, and roentgenograms of the chest show no evidence of past or present puImonary tubercuIous infection. In addi-
tion to being a primary case this is the onIy reported one, to our knowIedge, in which tubercuIosis of a retained cervix has been observed several years folIowing hysterectomy and bilatera1 saIpingo-oophorectomy for non-tubercuIous lesions. CASE
REPORT
A thirty-four year old femaIe was first admitted to St. Luke’s HospitaI on January 26, 1926, complaining of a tumor in the lower abdomen and dysmenorrhea. She had one child seven years old but had had no other pregnancies. Nothing eIse of importance was elicited in the history. PeIvic examination showed the cervix to be smah, hard and directed downward whiIe the uterine body was pushed to the Ieft by a firm, fixed mass in the right fornix. The bIood Wassermann was negative. The diagnosis of chronic salpingitis was made and Iaparotomy was performed. Both fallopian tubes were indurated, swoIIen, kinked and distorted by adhesions. The uterus was small and was bound to the adnexae by firm adhesions. Supravaginal hysterectomy and bilateral salpingo-oophorectomy were performed. The patient made an uneventful recovery except for a mild pyeIitis and she was discharged from the hospital with a we11 * From Surgical Division August,
1949
healed wound on the nineteenth postoperative day. PathologicaIIy, the specimen consisted of the body of the uterus and both tubes and ovaries. The fundus of the uterus was covered by shaggy adhesions. The cavity was smaI1 and the muscIe and mucosa were somewhat hypertrophied. Both tubes and ovaries were edematous and eIongated. HistoIogic study of the endometrium showed hyperpIasia and evidences of chronic infection, the stroma being moderateIy infiItrated and the increased, gIands diIated and fiIIed with secretion. The uterine muscIe was aIso slightly infiItrated and edematous. The tubes showed a Iate stage of chronic pyogenic suppuration; the Iumina were ditated and the mucosa was very much hypertrophied and infiItrated throughout with Iarge numbers of Iymphocytes and pIasma ceIIs. There was no evidence of tuberculosis. The diagnosis was chronic endometritis and chronic saIpingo-oophoritis. The patient was re-admitted to St. Luke’s HospitaI on September 20, 1931, CompIaining of a thin, watery vagina1 discharge of ten weeks duration. Several times there had been sIight bleeding but during the two weeks prior to her admission there had been more constant bleeding without hemorrhages. She had Iost 4 or 6 pounds in weight. Careful questioning failed to revea1 any past or present tubercuIosis in any member of her family and knowledge of genita1 tubercuIosis in her husband, from whom she is now separated, was denied. The patient was a we11 developed and we11 nourished negro. Except for the IocaI pelvic condition no other physica abnormaIities couId be made out. The bIood Wassermann was negative. X-rays of the chest were essentiaIIy normal. PeIvic examination showed a firm perineum which gave good support. The uterine body was missing and the vaults were shortened. The cervix was irregular and hard. On the posterior Iip there was a smaI1, friable, bIeeding, fungating mass which extended upward on to the vagina1 waI1 toward the Ieft
B and the PathoIogicaI Laboratory
273
of St. Luke’s HospitaI, New York, N. Y.
274
Shore,
Moore-Tuberculosis
of
Cervix
Uteri
smooth, completeIy heaIed over and showed The no evidence of residua1 tubercuIosis.
patient was seen at reguIar intervaIs and remained we11 until 1940 when, because of bIeedof the cervix was ing, a benign papiIIoma removed in the out-patient department. HistoIogic study of this benign tumor showed no evidence’ of tubercuIosis. BIeeding ceased following remova of this poIyp and the patient was symptom-free until May, 1943, when vagina1 bIeeding recurred and the patient Iost 15 pounds in weight. Sharp curettage of the cervix yieIded typica tubercuIous granuIation tissue. No other treatment was given and when she was Iast seen on September 3, 1947, sixteen years after primary treatment for the tubercuIous cervix, the patient was we11 and free from symptoms. Examination at this time discIosed hyperemia of the vagina1 mucous membrane but no ulcers or granuIating areas. Histologic study of a smaI1 portion of this reddened epitheIium showed onIy chronic vaginitis with no evidence of tubercuIosis. SUMMARY
FIG. 1. Photomicrograph cuIous lesion.
of primary
cervical
tuber-
broad Iigament. CIinicaIly the Iesion was thought to be a carcinoma. Under genera1 anesthesia a biopsy was taken for histoIogic study. Four, IO mg. radium needIes were inserted directIy into the Iesion and packed in place with two strips of iodoform gauze. This radium remained in pIace for forty-eight hours, giving a tota dose of 1,920 mg. hours. HistoIogic study of the biopsy specimen removed from the cervix uteri showed a portion of the squamous epithelium which was hypertrophied to a very unusua1 degree. The undedying fibrous stroma was converted into a mass of tubercuIous tissue. There were confluent and discreet tubercIes with many Langhans’ giant ceIIs, endotheIia1 ceIIs and Iymphocytes. The diagnosis of tuberculosis of the cervix uteri was made. (Fig. I .) The patient was discharged from the hospita1 on her sixth postoperative day. At her first follow-up visit on January 26, 1932, four months after the radium treatment, she was entirely free from symptoms. The cervix was
A patient with tubercuIosis of the uterine cervix, which occurred five years foIIowing supravaginal amputation of the uterus and biIatera1 saIpingo-oophorectomy for non-tubercuIous Iesions, is alive and symptom-free sixteen years foIIowing the initia1 treatment with radium. This is the onIy reported case, to our knowIedge, in which tuberculosis of a retained cervix has been observed severa years after hysterectomy and biIatera1 saIpingo-oophorectomy for non-tubercuIous Iesions. REFERENCES
of the cervix. Am. J. Obst. t? Gynec., 20: 24~25 I, 1930. 2. ENNIO, BORTONI. Di un case di tubercolosi primitiva Iocalizzata aI canale cervicale. Ann. di ostet. e gmec., 52: 112o-1135, 1930. 3. LANTEJOUL, P. Un cas de tuberculose genitale chez Ia femme. Bull. Sot. gyntc. et d’obst., 2 I : 432-433, I. HARRIS, B. A. TubercuIosis
1932. 4. DANNREUTHER, W. T. Discussion of a paper by B. P. Watson, TubercuIosis of the cervix uteri. Am. J. Obst. u Gynec., 27: 739. 1934. 4. TASCHE, J. Primarv tuberculosis of the cervix-a case’report. Wisconsin M. J., 39: 526527, 1940. 6. DENTON, J. F. TubercuIosis of the cervix. J. M. A. Georgia, 33: 37-40, 1944.
American
Journal
of Surgery