An intriguing case of endometrial tuberculosis presenting as irregular menstrual bleeding

Abstract

Endometrial tuberculosis (TB) is a rare form of tuberculosis infection. The diagnosis is not straightforward due to the nature of its presentation. We report a case of endometrial TB in a young, healthy and immunocompetent patient, who presented with irregular menstrual bleed. Her endometrial pipelle sampling revealed features of caseating granulomatous inflammation due to TB. We discuss the diagnostic modalities and treatment in this case.

Introduction

Female genital tuberculosis (TB) is a rare occurrence in developing countries. It can cause chronic pelvic inflammatory disease, menstrual abnormalities, and infertility. The exact incidence of genital TB cannot be assessed accurately because it is often silent and only 50% of cases are diagnosed. The reported incidence varies between 0.69% in developed countries to 19% in the developing world. ¹ Commonly TB affects the lungs, and genital TB is a secondary infection. Genital TB represents 15–20% of extra-pulmonary TB. ¹ Genital TB is a secondary infection acquired by hematogenous spread from an extragenital source such as pulmonary or abdominal TB. The fallopian tubes are site most commonly affected, followed by the endometrium and cervix. The disease affects women of reproductive age (15–54 years), causing infertility in 44–74% of those affected. ¹

Case presentation

A 40-year-old woman presented with irregular and heavy menstrual bleeding for duration of 1 year. The irregularity was described as prolonged duration of her menses which alternated with her normal menses duration, which was also associated with history of intermenstrual bleeding. She had undergone a dilatation and curettage procedure for a miscarriage 1 year previous. She was a mother of four, and her last childbirth was 8 years ago. She denied any history of having chronic cough, no night sweats, no loss of weight and no loss of appetite. She had no known medical or surgical illness and the family history was not contributory. Physical examination revealed a well-built lady with body mass index of 23. Her lungs were clear, and her abdominal examinations revealed normal findings. Pelvic and perineum examination revealed normal findings. The uterus was not enlarged and non-tender. Speculum examination revealed normal appearance of the cervix, with no discharge from the cervical os. Examination of other systems was unremarkable.

Her abdominal and pelvic ultrasounds were normal. She was offered endometrial pipelle sampling, in view of her symptoms of irregular menses, to look for any endometrial pathology such as endometrial malignancy or endometritis, which revealed caseating granulomatous inflammation due to TB (Figures 1–3). Unfortunately no endometrial sample was sent for microbiological cultures to confirm the sub-type of TB. Her chest radiograph was clear, and her Mantoux test was positive with a reading of 20 mm skin induration associated with blisters. Other investigations to exclude other concomitant pelvic infections such as HIV, hepatitis, VDRL, chlamydia or gonorrhea revealed normal results. No hormonal profile assessment was done on the patient to exclude other possible causes of her irregular menses, though these tests would be deemed necessary to shed more light on the patient’s diagnosis. The diagnosis was explained to the patient and she was offered anti-TB treatment, with details of the medications and duration of therapy. She was then started on anti-TB treatment. Upon review in clinic, after completion of 2 months of intensive phase treatment, her irregular menstrual bleed had resolved, and she resumed her normal menses throughout her follow-up, until completion of her 6-month regime of anti-TB treatment.

Figure 1.

Endometrial stroma is heavily infiltrated by inflammatory cells, forming epithelioid granulomata, some with central caseating necrosis.

Figure 2.

The granuloma composed of aggregates of epithelioidhistiocytes with scattered Langhan-type multinucleated giant cells, rimmed by lymphoid cells.

Figure 3.

Ziehl–Neelsen stain demonstrates presence of multiple acid-fast bacilli (Mycobacterium tuberculosis) which are stained bright red against a blue tissue background.

Discussion

Tuberculosis is one of the oldest known infections that affect pulmonary and extra-pulmonary sites. Genital TB often remains silent or may present with very few specific symptoms. The tubercular bacilli can lie dormant and can show reactivation when host immunity is low. Genital TB may present with a variety of gynecological symptoms of infertility, menstrual disturbance, and chronic pelvic pain. ² In our patient, the presentation was in the form of irregular menses.

One of the long-term complications of genital TB is infertility. Hence, early diagnosis and treatment are crucial. The most common site to be infected by TB is the fallopian tubes (95–100%), followed by endometrium (50–60%), ovaries (20–30%), the cervix (5–15%), vulva/vagina (1%), and the myometrium (2.5%). ² The disease often remains asymptomatic or may present with non-specific symptoms. ² Hence, the prevalence of genital TB has been underestimated. TB endometritis is rare and less common than TB infection of the fallopian tubes. Infertility in such cases is usually caused by TB infection of the tubes causing fibroisis or hydrosalpinges. Fertility is more of a concern in the younger reproductive age group of 25–35 years. Advanced age can also contribute to fertility issues besides infection.

The risk factors include a history of previous pulmonary TB, low socioeconomic background, residence in high-prevalence areas and immunocompromised status as in drug abusers, HIV-positive status. Our patient did not have all of the abovementioned risk factors, other than living in high-prevalence areas. The patient is a local Malaysian by birth, and she had completed her childhood BCG immunization. The patient is immunocompetent, hence not vulnerable to TB. Even though her chest radiograph was reported as normal, there is a possibility that she might had micro cavitary TB which could not be detected via chest radiograph, hence a high-resolution computed tomography thorax might be useful. Computed tomography abdomen and pelvis would also be useful to determine any potential intra-peritoneal spread of the TB infection, in view of the confirmation of the patient’s TB endometritis. However, further imaging tests were not done in our patient, due to her refusal, as she had some financial constraint. Good history taking, thorough clinical examination and judicious use of investigations may help in early diagnosis and timely treatment, preventing infertility and other devastating sequelae. ³

A study conducted at the University Hospital, Kuala Lumpur from March 1968 to February 1985 revealed that TB of the genital tract was diagnosed in only 12 patients during the 17-year period. The incidence was 0.31 per 1000 gynecological admissions, and the peak age incidence was in the age group 26–35 years. Surgical management was mainly conservative, as infertility was the most frequent mode of presentation (50%). Evidence of previous pulmonary TB was present in only five cases. Adnexal adhesions were the most common pelvic finding, while the fallopian tubes and endometrium were affected with equal frequency. Positive cultures for Mycobacterium tuberculosis were obtained in only five of the 12 patients. All patients received combination anti-TB drugs with satisfactory response. ⁴ In our case, this case is the first to occur in our hospital from 2005 until 2015, and the patient had no history of previous TB.

Conclusion

Tuberculosis is a multi-systemic disease with myriad presentation. A thorough history, coupled with complete physical examination and necessary investigations are essential, especially in detecting rare forms of extra-pulmonary TB. Although endometrial TB is generally seen in immunocompromised patients, whenever symptoms point to a pathology of the genitourinary system in a country with high TB prevalence, endometrial TB should be kept in mind as a differential diagnosis. A common gynecological problem may turn out to be of infectious disease origin. Hence, a multi-disciplinary approach is crucial for management of such cases. The involvement of a gynecologist, microbiologist, national epidemiologist in infectious disease and infectious disease specialist are paramount to ensure optimum care of such patients.