Genital Tuberculosis - An Unusual Presentation

Author Information

Bijapur S*, Parulekar SV**.
(* Second Year Resident, ** Professor and Head, Department of Obstetrics and Gynecology, Seth G.S. Medical College and K.E.M. Hospital, Mumbai, India.)

Abstract

Endometrial tuberculosis is a condition that can be asymptomatic, or can be present even in the absence of any physical findings both on clinical examination as well as endoscopic evaluation. We present a case of a 37 year old parous woman with hypomenorrhea followed by secondary amenorrhea due to end organ defect. She was ubusual in that she had no physical findings of tuberculosis and had amenorrhea despite the endometrium not being replaced by fibrous tissue, and which was cured with antituberculous therapy for just 2 months.

Introduction

Genital tuberculosis can cause a variety of symptoms like amenorrhea, abnormal uterine bleeding, pelvic pain, infertility, pelvic masses, abdominal masses, ascites etc. It can be suspected on investigations like hemogram, pelvic ultrasonography, hysterosalpingography, hysteroscopy and laparoscopy. The diagnosis can be confirmed by tests like TB-PCR, microbiologic studies on endometrium, and endometrial histopathology. It is unusual to have a case with secondary amenorrhea in presence of normal hysteroscopy and laparoscopy findings and the diagnosis being made by both TB-PCR test and histopathology. It is even more unusual to have the amenorrhea in the absence of replacement of the endometrium by fibrous tissue and reversal of the amenorrhea by antituberculous therapy for just two months. We present here such an unusual case.

Case Report

A 37 year old female , married for 13 years, para 2 living 2 MTP 1 presented with complaints of hypomenorrhea for 2 years , cycles every month lasting for 1 day, changing 1 pad per day and amenorrhea for 3 months. There was no pain in abdomen, foul smelling discharge, fever, loss of weight, loss of appetite. She was otherwise well and had no significant medical history. She had no history of tuberculosis or contact with tuberculosis. History of check curettage done in September 2016. General and systemic examination revealed no abnormality except mild enlargement of thyroid . On per speculum examination vagina was healthy and  cervix congested. On bimanual pelvic examination the uterus was anteverted, bulky, deviated to left and bilateral fornices were free. Pap smear showed inflammatory cells. Her rpogesterone and estrogen challenge tests were negative, and endometrial tuberculosis was suspected. Her chest radiograph, hemogram, liver and renal function tests were normal. Her thyroid function tests showed mild hypothyroidism, for which she was put on thyroid replacement therapy. Hysterroscopy, laparoscopy and cervical dilatation and endometrial curettage were performed. Hysteroscopy showed normal cervical canal, uterine cavity and tubal ostia. The endometrium was pale and flat.  Laparoscopy revealed normal abdominal and pelvic findings. Her endometrium was sent for TB-PCR and histopathological examination. Both tests confirmed the diagnosis of endometrial tuberculosis. She was put on category 1 antituberculous therapy, which she tolerated well, and started menstruating in two months.

Discussion

Genital tuberculous infection is usually caused by hematogenous spread from a primary site, usually in the lungs. [1]. The commonest site is the fallopian tubes (100%), followed by endometrium (50%), ovaries (20%), cervix (5%), and vagina and vulva in (<1%). [2,3] The patients present with infertility, pelvic pain, abnormal vaginal bleeding, amenorrhea, and vaginal discharge in 44%, 25%, 18%, 5%, 4% cases respectively. [4] Less common features include include abdominal mass, tuboovarian mass or abscess and ascites. [5]

The case presented by us was unusual in many respects. The patient was healthy and well, except having hypomenorrhea in the past and amenorrhea at present. Her general and systemic examination and investigations did not reveal anything suggestive of pelvic tuberculosis. It is usual to find some feature of tuberculosis on hysteroscopy and laparoscopy. In this patient all endoscopic findings were normal. Amenorrhea in a case of genital tuberculosis is usually due to replacement of endometrium by fibrous tissue (Asherman syndrome). It has been stated that the general toxemia of tuberculosis can cause amenorrhea in the absence of endometrial disease. However there is no evidence to support this statement. A negative estrogen challenge test strongly suggested the diagnosis. Hence the endometrium was sent for TB-PCR as well as histopathological examination, even though the findings on hysteroscopy and laparoscopy were normal, and there was no evidence of tuberculosis. It was surprising that both the tests were positive for tuberculosis. PCR is far more sensitive in detecting genital tuberculosis than microbiologic smear and culture methods. [6,7,8] But it is not usual to find the TB-PCR test positive when there are no gross features of tuberculosis on endoscopy. TB-PCR can be false negative as well as false positive. [9]

Endometrial tuberculosis can be present even when chest radiography, hemogram, hysteroscopy and laparoscopy do not show any feature suggestive of genital tuberculosis. In presence of other supportive evidence, a positive PCR test can be considered to be diagnostic of tuberculosis. In our case the endometrial histopathology confirmed the diagnosis, and the TB-PCR test turned out to be unnecessary in hindsight. However the likelihood of having a positive diagnosis on histopathology was considered to be low, and hence TB-PCR test was asked for. The patient started normal menstruation within two months of starting antituberculous therapy, which suggests presence of some factor in the endometrium that causes amenorrhea in the absnce of fibrosis replacing the endometrium, and even a short course of antituberculous therapy can remove this factor so that menstruation can start again. Thus an early diagnosis is important and hence TB-PCR test should be done in suspected cases.

References

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Citation

Bijapur S, Parulekar SV. Genital Tuberculosis - An Unusual Presentation. JPGO 2017. Volume 4 No.6. Available from: http://www.jpgo.org/2017/06/genital-tuberculosis-unusual.html