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Tuberculous cervicitis mimicking cancer cervix: A case study
Middle East Fertility Society Journal (2014) 19, 75–77
Middle East Fertility Society
Middle East Fertility Society Journal www.mefsjournal.org www.sciencedirect.com
CASE REPORT
Tuberculous cervicitis mimicking cancer cervix: A case study Eman Elkattan *, Mona AbdElBadei, Hatem Hettow, Eman Hussein, Jina Assaad Department of Obstetrics and Gynecology, Cairo University, Cairo, Egypt Received 1 April 2013; accepted 7 May 2013 Available online 26 June 2013
KEYWORDS Tuberculosis; Cervical smear; Colposcopy; Tubercuolous cervicitis
Abstract Background: Primary Tuberculosis of the uterine cervix is an unusual event, with only a few cases reported in the English literature. Case report: A 25 year old nulligravid woman was referred to our hospital with suspected cervical carcinoma. General, gynecologic, colposcopic and microbiologic assessments were done. Diagnosis of cervical tuberculosis was confirmed on histologic examination. The patient received anti-tuberculous therapy and has been disease free for 12 months. Conclusion: Cervical tuberculosis may mimic cervical carcinoma and should be included in the differential diagnosis especially in endemic countries. Ó 2013 Production and hosting by Elsevier B.V. on behalf of Middle East Fertility Society.
1. Introduction Tuberculous infection (TB), which is now uncommon in Western society, is still frequently observed in Third World countries in Africa and Asia. The cervix is involved in 0.1–0.65% of all cases of tuberculosis and 5–10% of cases in female genital tract. Tuberculous involvement of the female genital tract in almost all cases is secondary to extragenital tuberculosis. Affectation of the female genitalia has been reported as a rare event (1). TB is usually secondary to a primary focus elsewhere in the body most commonly from lungs. Spread to cervix is * Corresponding author. Tel.: +20 1222854159. E-mail addresses: [email protected] (E. Elkattan), monanayel [email protected] (M. AbdElBadei), [email protected] (H. Hettow), [email protected] (E. Hussein). Peer review under responsibility of Middle East Fertility Society.
Production and hosting by Elsevier
either by hematogenous, lymphatic dissemination or by direct extension (2). The lesion on the cervix can be either exophytic, ulcerative although interstitial and endocervical polypoid form may also occur (3). We presented this case as the cervical tuberculosis is rare and can be easily misinterpreted clinically as cervical malignancy. 2. Case report A 25-year-old nulligravid Egyptian housewife, was referred to our clinic with a 5 year history of primary infertility and 8 year history of oligomenorrhea. She has been experiencing postcoital bleeding for 2 years. She denied any history of chronic cough or loss of weight. She had no history of immunodeficiency diseases or was on immunosuppressant medication. The fertility team referred her to the colposcopy clinic. There was no history of personal or family exposure to tuberculosis. There was no history of genital malignancy in the family. The patient was a non-smoker. She had no significant past medical history. On abdominal examination, no significant findings were found.
1110-5690 Ó 2013 Production and hosting by Elsevier B.V. on behalf of Middle East Fertility Society. http://dx.doi.org/10.1016/j.mefs.2013.05.005
76
E. Elkattan et al. analysis were negative. Tuberculin skin test was not done. The patient was referred to the department of chest diseases. Antituberculous medications were prescribed in the form of isoniazid (5 mg/kg), Rifampicin (10 mg/kg), Pyrazinamide (25 mg/Kg) and ethambutol (15 mg/kg). The treatment continued for 6 months. Her cervical smear follow ups were negative up to 1 year following treatment. There was no history of postcoital bleeding after the cone biopsy. Unfortunately, we did not have bacterial evidence on the cone biopsy but as tuberculosis was suggested by the pathologist and the fact that the patient improved on antituberculous treatment made it more likely that it is tuberculosis. A signed consent form from the patient had been obtained. 2.1. Discussion
Figure 1 Colposcopy picture of the cervix after applying acetic acid showing the irregular cervical mass with acetowhite changes on applying the acetic acid.
Figure 2 Histopathology of the cone showing the extensive epithelioid granulomata, Langhan’s giant cells and central necrosis suggesting tuberculous cervicitis.
Inspection of the vulva revealed no abnormality. On speculum examination: abnormally looking cervix was noted. There was an irregular cervical mass, which bled on touch. A smear was taken as well as endocervical swab for chlamydia and vaginal swab for vaginal infection. Bimanual examination showed a normal-sized, anteverted, anteflexed, mobile uterus with no palpable adnexal masses or tenderness; and confirmed the presence of a non-tender mass on the cervix. Fornices were normal and per rectal examination revealed no abnormality. Colposcopic examination showed increased vascularity with mild acetowhite changes (Fig. 1) and iodine negative areas. Multiple colposcopically guided punch biopsies were taken from the cervical growth and the acetowhite areas. The smear showed extensive inflammation without cervical intraepithelial lesion or malignancy, the swabs for infection revealed no abnormality and the biopsies revealed chronic cervicitis. As the patient continued to bleed, the decision was taken by the colposcopy team to do cone biopsy, which suggested TB cervicitis (extensive epithelioid granuloma, Langhan’s giant cells and central necrosis) (Fig. 2). Chest X-ray and sputum
In 2011, 8.7 million people fell ill with TB and 1.4 million died from TB. The Incidence of tuberculosis (per 100,000 people) in Egypt was last reported as 19 in 2011, according to a World Bank report published in 2012 (4). The incidence of TB has been increased recently especially in areas where HIV and TB are prevalent (5). Genitourinary tuberculosis (TB) is more prevalent in developing countries. Fallopian tubes and ovaries are commonly involved. Rarely, other pelvic organs like the vagina, vulva, myometrium and cervix may be involved. Cervical TB accounts for 0.1–0.65% of all cases of TB and 5–24% of genital tract TB (6). In rare cases, cervical TB may be a primary infection introduced from a partner with tuberculous epididymitis or other genitourinary diseases (7). Sputum used, as a sexual lubricant may also be a mode of transmission of genitourinary tuberculosis (1). Cervix is relatively resistant to tuberculosis infection because the stratified squamous epithelium of the ectocervix prevents bacterial penetration. In addition, cervical mucus is known to have antibacterial action. 50% of patients remain asymptomatic. Symptomatic genital tract TB usually presents with abnormal vaginal bleeding, menstrual irregularities, abdominal pain, and constitutional symptoms (3,8). The diagnosis of cervical TB is usually made by histological examination of a cervical biopsy specimen. Staining for acid-fast bacilli may not be very useful in making a diagnosis (9). Although isolation of mycobacterium is the gold standard for diagnosis, one third of cases are culture negative, therefore the presence of typical granulomata is sufficient for diagnosis if other causes of granulomatous cervicitis are excluded. New modalities and diagnostic tests could be considered such as Serodiagnosis by enzyme linked immunosorbent assay (ELISA), which increases the detection rate (10). PCR (Polymerase chain reaction) technique is also one of the recent advances for rapid detection of tuberculosis (11). Surgery is rarely indicated, usually in drug resistant cases. A case similar to present case, which had been confused with cervical malignancy, has been reported (8,12). 2.2. Educational message The possibility of Tuberculous cervicitis should be kept in mind in the differential diagnosis of suspicious cervix especially in areas where Tuberculosis is prevalent, taking into consideration the difficulty in the diagnosis of genital tuberculosis.
Tuberculous cervicitis mimicking cancer cervix: Acase study References (1) Samantaray S, Parida G, Rout N, Giri SK, Kar R. Cytologic detection of tuberculous cervicitis: a report of 7 cases. Acta Cytol 2009;53(5):594. (2) 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. (3) Sinha A, Banerjee N, Roy KK, Takkar D. Cervical tuberculosis mimicking carcinoma cervix. J Obstet Gynecol India 2002;52:154. (4) Global tuberculosis control: surveillance, planning, financing: WHO report 2011, Geneva: World Health Organization; 2011 (WHO/HTM/TB/2011.16). (5) Akhlaghi F, Hamedi A. Postmenopausal Tuberculosis of the cervix, vagina and vulva. Internet J Gynecol Obstet 2004;3(1). http://dx.doi.org/10.5580/15e. (6) 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.
77 (7) Jaiprakash P, Pai K, Rao L. Diagnosis of tuberculous cervicitis by Papanicolaou-stained smear. Ann Saudi Med 2013;33(1):76–8. (8) Singh S, Gupta V, Modi S, Rana P, Duhan A, Sen R. Tuberculosis of uterine cervix: a report of two cases with variable clinical presentation. Trop Doct 2010:40125–6. (9) Kalyani R, Sheela S, Rajini M. Cytological diagnosis of tuberculous cervicitis: a case report with review of literature. J Cytol 2012;29(1):86–8. (10) Shin AR, Shin SJ, Lee KS, Eom SH, Lee SS, Lee BS, Lee JS, Cho SN, Kim HJ. Improved sensitivity of diagnosis of tuberculosis in patients in Korea via a cocktail enzyme-linked immunosorbent assay containing the abundantly expressed antigens of the K strain of Mycobacterium tuberculosis. Clin Vaccine Immunol 2008;15(12):1788–95. (11) Honore´-Bouakline S, Vincensini JP, Giacuzzo V, Lagrange PH, Herrmann JLJ. Rapid diagnosis of extrapulmonary tuberculosis by PCR: impact of sample preparation and DNA extraction. Clin Microbiol 2003;41(6):2323–9. (12) Agarwal S, Madan M, Leekha N, Raghunandan C. A rare case of cervical tuberculosis simulating carcinoma of cervix: a case report. Cases J 2009;2:161.
Middle East Fertility Society
Middle East Fertility Society Journal www.mefsjournal.org www.sciencedirect.com
CASE REPORT
Tuberculous cervicitis mimicking cancer cervix: A case study Eman Elkattan *, Mona AbdElBadei, Hatem Hettow, Eman Hussein, Jina Assaad Department of Obstetrics and Gynecology, Cairo University, Cairo, Egypt Received 1 April 2013; accepted 7 May 2013 Available online 26 June 2013
KEYWORDS Tuberculosis; Cervical smear; Colposcopy; Tubercuolous cervicitis
Abstract Background: Primary Tuberculosis of the uterine cervix is an unusual event, with only a few cases reported in the English literature. Case report: A 25 year old nulligravid woman was referred to our hospital with suspected cervical carcinoma. General, gynecologic, colposcopic and microbiologic assessments were done. Diagnosis of cervical tuberculosis was confirmed on histologic examination. The patient received anti-tuberculous therapy and has been disease free for 12 months. Conclusion: Cervical tuberculosis may mimic cervical carcinoma and should be included in the differential diagnosis especially in endemic countries. Ó 2013 Production and hosting by Elsevier B.V. on behalf of Middle East Fertility Society.
1. Introduction Tuberculous infection (TB), which is now uncommon in Western society, is still frequently observed in Third World countries in Africa and Asia. The cervix is involved in 0.1–0.65% of all cases of tuberculosis and 5–10% of cases in female genital tract. Tuberculous involvement of the female genital tract in almost all cases is secondary to extragenital tuberculosis. Affectation of the female genitalia has been reported as a rare event (1). TB is usually secondary to a primary focus elsewhere in the body most commonly from lungs. Spread to cervix is * Corresponding author. Tel.: +20 1222854159. E-mail addresses: [email protected] (E. Elkattan), monanayel [email protected] (M. AbdElBadei), [email protected] (H. Hettow), [email protected] (E. Hussein). Peer review under responsibility of Middle East Fertility Society.
Production and hosting by Elsevier
either by hematogenous, lymphatic dissemination or by direct extension (2). The lesion on the cervix can be either exophytic, ulcerative although interstitial and endocervical polypoid form may also occur (3). We presented this case as the cervical tuberculosis is rare and can be easily misinterpreted clinically as cervical malignancy. 2. Case report A 25-year-old nulligravid Egyptian housewife, was referred to our clinic with a 5 year history of primary infertility and 8 year history of oligomenorrhea. She has been experiencing postcoital bleeding for 2 years. She denied any history of chronic cough or loss of weight. She had no history of immunodeficiency diseases or was on immunosuppressant medication. The fertility team referred her to the colposcopy clinic. There was no history of personal or family exposure to tuberculosis. There was no history of genital malignancy in the family. The patient was a non-smoker. She had no significant past medical history. On abdominal examination, no significant findings were found.
1110-5690 Ó 2013 Production and hosting by Elsevier B.V. on behalf of Middle East Fertility Society. http://dx.doi.org/10.1016/j.mefs.2013.05.005
76
E. Elkattan et al. analysis were negative. Tuberculin skin test was not done. The patient was referred to the department of chest diseases. Antituberculous medications were prescribed in the form of isoniazid (5 mg/kg), Rifampicin (10 mg/kg), Pyrazinamide (25 mg/Kg) and ethambutol (15 mg/kg). The treatment continued for 6 months. Her cervical smear follow ups were negative up to 1 year following treatment. There was no history of postcoital bleeding after the cone biopsy. Unfortunately, we did not have bacterial evidence on the cone biopsy but as tuberculosis was suggested by the pathologist and the fact that the patient improved on antituberculous treatment made it more likely that it is tuberculosis. A signed consent form from the patient had been obtained. 2.1. Discussion
Figure 1 Colposcopy picture of the cervix after applying acetic acid showing the irregular cervical mass with acetowhite changes on applying the acetic acid.
Figure 2 Histopathology of the cone showing the extensive epithelioid granulomata, Langhan’s giant cells and central necrosis suggesting tuberculous cervicitis.
Inspection of the vulva revealed no abnormality. On speculum examination: abnormally looking cervix was noted. There was an irregular cervical mass, which bled on touch. A smear was taken as well as endocervical swab for chlamydia and vaginal swab for vaginal infection. Bimanual examination showed a normal-sized, anteverted, anteflexed, mobile uterus with no palpable adnexal masses or tenderness; and confirmed the presence of a non-tender mass on the cervix. Fornices were normal and per rectal examination revealed no abnormality. Colposcopic examination showed increased vascularity with mild acetowhite changes (Fig. 1) and iodine negative areas. Multiple colposcopically guided punch biopsies were taken from the cervical growth and the acetowhite areas. The smear showed extensive inflammation without cervical intraepithelial lesion or malignancy, the swabs for infection revealed no abnormality and the biopsies revealed chronic cervicitis. As the patient continued to bleed, the decision was taken by the colposcopy team to do cone biopsy, which suggested TB cervicitis (extensive epithelioid granuloma, Langhan’s giant cells and central necrosis) (Fig. 2). Chest X-ray and sputum
In 2011, 8.7 million people fell ill with TB and 1.4 million died from TB. The Incidence of tuberculosis (per 100,000 people) in Egypt was last reported as 19 in 2011, according to a World Bank report published in 2012 (4). The incidence of TB has been increased recently especially in areas where HIV and TB are prevalent (5). Genitourinary tuberculosis (TB) is more prevalent in developing countries. Fallopian tubes and ovaries are commonly involved. Rarely, other pelvic organs like the vagina, vulva, myometrium and cervix may be involved. Cervical TB accounts for 0.1–0.65% of all cases of TB and 5–24% of genital tract TB (6). In rare cases, cervical TB may be a primary infection introduced from a partner with tuberculous epididymitis or other genitourinary diseases (7). Sputum used, as a sexual lubricant may also be a mode of transmission of genitourinary tuberculosis (1). Cervix is relatively resistant to tuberculosis infection because the stratified squamous epithelium of the ectocervix prevents bacterial penetration. In addition, cervical mucus is known to have antibacterial action. 50% of patients remain asymptomatic. Symptomatic genital tract TB usually presents with abnormal vaginal bleeding, menstrual irregularities, abdominal pain, and constitutional symptoms (3,8). The diagnosis of cervical TB is usually made by histological examination of a cervical biopsy specimen. Staining for acid-fast bacilli may not be very useful in making a diagnosis (9). Although isolation of mycobacterium is the gold standard for diagnosis, one third of cases are culture negative, therefore the presence of typical granulomata is sufficient for diagnosis if other causes of granulomatous cervicitis are excluded. New modalities and diagnostic tests could be considered such as Serodiagnosis by enzyme linked immunosorbent assay (ELISA), which increases the detection rate (10). PCR (Polymerase chain reaction) technique is also one of the recent advances for rapid detection of tuberculosis (11). Surgery is rarely indicated, usually in drug resistant cases. A case similar to present case, which had been confused with cervical malignancy, has been reported (8,12). 2.2. Educational message The possibility of Tuberculous cervicitis should be kept in mind in the differential diagnosis of suspicious cervix especially in areas where Tuberculosis is prevalent, taking into consideration the difficulty in the diagnosis of genital tuberculosis.
Tuberculous cervicitis mimicking cancer cervix: Acase study References (1) Samantaray S, Parida G, Rout N, Giri SK, Kar R. Cytologic detection of tuberculous cervicitis: a report of 7 cases. Acta Cytol 2009;53(5):594. (2) 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. (3) Sinha A, Banerjee N, Roy KK, Takkar D. Cervical tuberculosis mimicking carcinoma cervix. J Obstet Gynecol India 2002;52:154. (4) Global tuberculosis control: surveillance, planning, financing: WHO report 2011, Geneva: World Health Organization; 2011 (WHO/HTM/TB/2011.16). (5) Akhlaghi F, Hamedi A. Postmenopausal Tuberculosis of the cervix, vagina and vulva. Internet J Gynecol Obstet 2004;3(1). http://dx.doi.org/10.5580/15e. (6) 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.
77 (7) Jaiprakash P, Pai K, Rao L. Diagnosis of tuberculous cervicitis by Papanicolaou-stained smear. Ann Saudi Med 2013;33(1):76–8. (8) Singh S, Gupta V, Modi S, Rana P, Duhan A, Sen R. Tuberculosis of uterine cervix: a report of two cases with variable clinical presentation. Trop Doct 2010:40125–6. (9) Kalyani R, Sheela S, Rajini M. Cytological diagnosis of tuberculous cervicitis: a case report with review of literature. J Cytol 2012;29(1):86–8. (10) Shin AR, Shin SJ, Lee KS, Eom SH, Lee SS, Lee BS, Lee JS, Cho SN, Kim HJ. Improved sensitivity of diagnosis of tuberculosis in patients in Korea via a cocktail enzyme-linked immunosorbent assay containing the abundantly expressed antigens of the K strain of Mycobacterium tuberculosis. Clin Vaccine Immunol 2008;15(12):1788–95. (11) Honore´-Bouakline S, Vincensini JP, Giacuzzo V, Lagrange PH, Herrmann JLJ. Rapid diagnosis of extrapulmonary tuberculosis by PCR: impact of sample preparation and DNA extraction. Clin Microbiol 2003;41(6):2323–9. (12) Agarwal S, Madan M, Leekha N, Raghunandan C. A rare case of cervical tuberculosis simulating carcinoma of cervix: a case report. Cases J 2009;2:161.