Author Information
Gewndolyn Fernandes*, Parulekar SV**
(* Associate Professor, Department of Pathology, ** Professor
and Head, department of Gynecology and Obstetrics; Seth GS Medical College
& KEM Hospital, Mumbai, India)
Abstract
Endometrium can develop a number of chronic granulomatous as
well as nongranulomatous inflammatory lesions. We present a case of an
endometrial microscopic foreign body of plant origin. This is the first case of
its type in the world literature.
Introduction
The endometrium can
be affected by a number of inflammatory agents, infectious as well as
noninfectious. Infections include tuberculosis, atypical mycobacterial infection, actinomycosis,
endemic mycosis, and parasitic infestation. Noninfectious conditions
include foreign body reaction, sarcoidosis, lymphoma and other
neoplastic conditions, Crohn disease,
and operative trauma. We present a case of an endometrial foreign body reaction
that was focal and microscopic, the foreign body being of plant origin. This is
the first case of a microscopic foreign body in the endometrium with chronic
inflammation in the world literature.
Case Report
A 54 year old woman presented with a second degree uterine
prolapse, moderate cystocele and moderate rectocele. She had been married for
30 years. She had a normal delivery 27 years ago and a medical termination of
pregnancy at 2 months of amenorrhea by medical method 25 years ago. Check
curettage had not been done at that time. She had undergone laparoscopic
sterilization 17 years ago and an appendectomy 8 years ago. She developed
pulmonary tuberculosis 6-7 years ago, and had received full treatment for it.
She was found to be cured after that treatment. She was menopausal for 3-4
years. There was no history of use of any herbal preparations vaginally at any
time in her life. A vaginal hysterectomy with vaginal prolapse repair using
site specific method was done. She made an uneventful recovery. She was all
right at follow up after 15 days, 1 month and 2 years.
Gross examination of the
specimen showed that the uterus measured 7x0.8x1 cm. The cervix was
keratinized. On cutting the uterus open, the endometrium was 0.2 cm thick, the
myometrium was 0.6 cm thick. The endometrium and myometrium were grossly normal.
Microscopic examination showed a small foreign body of plant origin in the
endometirum of the corpus. It was composed of cells with thick, rigid cell
walls arranged end to end. A brownish pigment was also seen in the cells. These
features were typical of plant origin cells. Animal cells have thin cell
membranes. The foreign body was surrounded by dense fibrinous material and
neutrophils. Indentation of the surface was seen by the foreign body. The
endometrium showed atrophic features. The myometrium showed calcification of
the wall of small arterioles. The cervix showed features of chronic cervicitis
with prominent keratinization of the squamous epithelium and squamous
metaplasia of the endocervical glands.
Figure 1. Microphotograph showing foreign body with an intense reaction
around it and indentation of the endometrial surface. Atrophic endometrial
glands are seen. (H&E x100)
Figure 2. Microphotograph of a higher magnification showing the foreign
body composed of plant origin cells with thick cell walls. Fibrinous material
and neutrophils are seen around it. (H&E x 400)
Figure 3. Some of the plant origin cells are cut in transverse section
and show brownish pigment. (H&E x 400)
Figure 4. Oil immersion view showing plant origin cells with thick rigid
cell walls and cells arranged end to end. (H&E x 1000)
Discussion
Insertion of foreign bodies into the vagina is much more
common than into the uterine cavity, because the patient or someone else can do
it easily. Insertion of foreign bodies into the uterine cavity is much more
difficult. It requires some training, and is usually done as a part of therapy
by the doctor or for achieving criminal abortion by quacks. Microscopic foreign
particles may enter the uterine cavity along the cervical mucus, aided by the
ciliary action of the endocervical cells. It occurs in case of sperm and has
been shown to occur experimentally too.[1,2] Since this patient gave
no history of insertion of any foreign body into the genital tract, either by
self or by a doctor or a quack for any reason, the microscopic foreign body of
plant origin in her endometrium cannot be explained easily.
Twigs of certain plants have been inserted into the uterine
cavity to achieve illegal (criminal) abortions.[2,3,4,5] It is
possible that a portion of the foreign body remains in the uterine cavity and
elicits chronic inflammatory response. This patient refused having undergone
any such procedure. It is possible that she had it done and was denying it out
of fear of disclosure.
Aegle marmelos (Bilva, wood apple tree) is a plant with
medicinal value in Ayurveda. Its fruit extracts have been used by Ayurvedic
physicians for its astringent action in the management of chronic diarrhea and
dysentery, hemorrhoids, and possibly genital prolapse. It is used orally for
control of gastrointestinal symptoms and vaginally (pichu) for local
symptoms.[6] It is possible that this patient tried the vaginal
administration of this preparation for her genital prolapse and hid the fact
when it failed to cure her and she presented to us for management. The
particles in the pichu might have ascended to reach the endometrium and
caused chronic inflammation.
Another possibility is that the patient sat on the ground
without undergarments, and the prolapsed cervix picked up plant debris from the
ground. Microscopic particles of the same may have traveled up the uterus
passively and set up a chronic inflammatory reaction. Foreign bodies like
foreign material from glove talc or suture may cause foreign body reaction in
the endometrium in women who have undergone surgery in that area. Use of surgical diathermy can also elicit
such reaction in the endometrium.[7] This patient did not have any
uterine surgery in the past.
The lesion found in the endometrium of this patient was a
chronic inflammatory reaction to a foreign body of plant origin, distinct from
all granulomas, as can be found with tuberculosis, schistosomiasis, Enterobius vermicularis
infestation, coccidiomycosis, cytomegalovirus, sarcoidosis,
granulomatous vasculitis,
radiation, and ceroid granulomas.[9,10,11,12,13,14]
Conclusion
Microscopic chronic endometrial
focal inflammation can be because of a number of conditions. It needs to be
differentiated from granulomatous lesions which have a much worse prognosis. A
foreign body of plant origin may enter the genital tract due to self insertion,
criminal abortion with an abortion stick, or possibly to uterine prolapse.
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Citation
Fernandes G,
Parulekar SV. Endometrial Microscopic Foreign Body. JPGO 2014. Volume
1 Number 11. Available from: http://www.jpgo.org/2014/11/endometrial-microscopic-foreign-body.html