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OJHAS Vol. 10, Issue 1:
(Jan-Mar 2011) |
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An Unusual Case of Cervical
Tuberculosis |
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Prashant S Joshi, Associate Professor, Dept. of Obstetrics & Gynaecology,
Vijay Shankar S, Associate Professor, Dept. of
Pathology,
Pushpee Sinha, Assistant Professor, Dept. of Obstetrics
& Gynaecology,
Adichunchanagiri Institute of Medical Sciences, BG Nagara, Nagamangala
Taluk, Mandya District, Karnataka, INDIA. |
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Address for Correspondence |
Associate
Professor,
Department of Obstetrics & Gynaecology,
Adichunchanagiri
Institute of Medical Sciences,
BG Nagara,
Mandya District,
Karnataka-571448, India.
E-mail:
joshpj@rediffmail.com |
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Joshi PS, Vijay Shankar S, Sinha P. An Unusual Case of Cervical
Tuberculosis. Online J Health Allied Scs.
2011;10(1):21 |
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Submitted: Feb 3,
2011; Accepted: March 30, 2011; Published:
April 15, 2011 |
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| Abstract: |
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Tuberculosis of the cervix is a rare disease and accounts to 0.1 – 0.65% of all
cases of tuberculosis and 5 – 24 % of genital tract tuberculosis.
We present an unusual case of 40 years old lady who
presented with irregular bleeding per vagina and foul smelling white discharge
for 1 year. Per speculum examination revealed an unhealthy looking
cervix which bled on touch. A clinical diagnosis of carcinoma cervix
was made. However, cervix biopsy revealed granulomatous
lesion suggestive of tuberculosis. The patient responded to antitubercular
therapy. In women with abnormal cervical
appearance, there should be high index of suspicion of tuberculosis
cervix, especially from areas where tuberculosis is common as it can be easily
treated.
Key Words:
Tuberculosis; Cervix
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Tuberculosis is highly prevalent
in India. However, genitourinary tuberculosis accounts for a minority of cases in young women of child bearing age and may
involve fallopian tubes, endometrium, and ovaries.1 Tuberculosis of cervix is
a rare disease which usually is not suspected clinically and can mimic
malignancy in post menopausal females.
A 40 years old lady (Para 1 living 1), manual labourer by occupation, presented with chief
complaint of irregular bleeding and foul smelling discharge per vagina
for one year. There was history of recent weight loss. There was no history of
genital malignancy in the past or in the family. Patient did
not have any other significant medical or surgical illness in the past.
General physical examination was essentially normal an dthere was no lymphadenopathy. Per speculum examination revealed an
unhealthy looking cervix which was grossly erythematous, congested and
bled on touch.(Fig. 1) On bimanual examination, uterus was anteverted
and normal in size. Fornices were free. Per rectal examination was normal.
Cervical smear study revealed extensive inflammation without any evidence
of intraepithelial lesion or malignancy.
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Figure 1:
Photograph showing unhealthy erythematous, congested cervix. |
Figure 2:
Photomicrograph showing endocervical glands and the stroma showing
epitheloid cell granulomas with Langhans type of giant cells. |
Microscopic
examination of the cervical biopsy revealed extensive epitheloid cell
granulomas with Langhans type of giant cells and focal necrosis (Figure
2).
Endometrial biopsy
was normal. Chest radiograph was normal and sputum and urine samples were negative for
AFB. HIV I,II were negative.
Patient was
started on antitubercular treatment,
CAT III Under RNTCP and was discharged. The patient is under
regular followup and is doing fine after 6 months.
Tuberculosis of the cervix is rare and accounts for 0.1-0.65% of all
cases of tuberculosis (TB) and 5-24% of genital tract TB.2
Symptomatic genital tract TB usually presents with abnormal vaginal
bleeding, menstrual irregularities, abdominal pain, and constitutional
symptoms. Tuberculosis of cervix can present with various ways and may at times even mimic malignancy.3
Pelvic organs are infected from a primary focus, usually the chest,
by haematogenous spread.1,4 Lymphatic spread or direct
infection is the mode of involvement of cervix. Often the primary
lesion would be healed at presentation. Rarely cervical TB can be a primary
infection introduced by a partner with tuberculous epididymitis or other
genitourinary disease.2,4 Chowdhury has suggested that sputum, used as a sexual lubricant, may
also be a route of transmission.1 As more than 80% of cases
occur in the reproductive age group, the possibility of hormonal dependence
of infection is also considered.4
The macroscopic findings of cervical TB can vary. There may be a hypertrophy
of the cervix or show friable papillary or vegetative growth with or
without ulceration, thus simulating invasive cervical cancer.5,6
The diagnosis of cervical TB is usually made by histological examination
of a cervical punch biopsy specimen. Microscopically there will be
an extensive chronic inflammation with the presence of caseating or noncaseating
granulomas in most of the cases. Staining with AFB may not reveal
the organisms. A retrospective review found that ulcerative lesions
usually are auramine negative. The detection of granulomata on cervical
cytology specimens has been documented.7 Isolation of the
mycobacterium is the gold standard for diagnosis. Up to one third of
patients can be culture negative.8 Molecular probes may be more
sensitive than culture but also have reduced specificity. Hence presence
of granulomas is considered sufficient enough to make a diagnosis after
excluding other causes of granulomatous cervicitis.
The other causes of granulomatous
inflammation of the cervix should be ruled out by performing anciliary
investigations for Chlamydia trachomatis and Neisseria gonorrhea.
The other rare causes of granulomatous cervicitis are schistosoma, brucella,
tularemia, sarcoidosis or a foreign body reaction.8
Generally the patients respond
to 6 months of standard antitubercular therapy. Regular follow
up of patient will be necessary to examine the lesion which would be
marker to access response to treatment which can be confirmed by histopathological
examination of serial biopsies.
The incidence of tuberculosis has increased
recently and is partly attributable to the HIV pandemic. The diagnosis
of cervical tuberculosis is difficult clinically as the symptoms and
physical examination usually do not give clues to the disease. Hence
in women with an abnormal cervical appearance, there should be a high
index of suspicion of tuberculosis, especially from areas where HIV
and TB are common as tuberculosis can be easily treated.
- Chowdhury NNR.
Overview of tuberculosis of the female genital tract. J Indian Med
Assoc 1996;94:345-361.
Carter JR. Unusual
presentations of genital tract tuberculosis. Int J Gynaecol Obstet
1990;33:171-176.
Bhalla A, Mannan
R, Bhasin TS. Tubercular cervicitis clinically mimicking as carcinoma
cervix: two case reports. Journal of Clinical and diagnostic research
2010;4:2083-2086
Richards MJ, Angus
D. Possible sexual transmission of genitourinary tuberculosis. Int J
TB Lung Dis 1998;2:439.
Shobin D, Sall
S, Pellman C. Genitourinary tuberculosis simulating cervical carcinoma.
J Reprod Med 1976;17:305–308.
Highman WJ. Cervical
smears in tuberculous endometritis. Acta Cytol 1972;16:16–20.
Samantaray S,
Parida G, Rout N, Giri SK, Kar R. Cytologic detection of tuberculous
cervicitis: a report of 7 cases. Acta Cytol. 2009;53:594-596.
Lamba H, Byrne
M, Goldin R, Jenkins C. Tuberculosis of the cervix: case
presentation and a review of the literature. Sex Transm Infect. 2002;78:62-63.
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