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Tubercular cervicitis clinically

mimicking as carcinoma cervix: Two
case reports
Rahul Mannan

Journal of Clinical and Diagnostic Research

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Tubercular Cervicitis Clinically Mimicking As

Carcinoma Cervix: Two Case Reports

Article in Journal of Clinical and Diagnostic Research · February 2010

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 Tubercular Cervicitis Clinically Mimicking As Carcinoma
Cervix: Two Case Reports

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_______________________________ Manchester repair was planned. The pouch
L LL LLL LLLL ; ? of Douglas was opened and the uterus was
; > 17 2 1 %; B ' found to be adherent. A clinical diagnosis
# $! $ %
of frozen pelvis was made and malignancy
@8 5 0 ? was suspected. The cervix was partially
I+ +#&*""# amputated and was sent for
; B %2 ' histopathological examination.
; + MF#F&,*I&I!I %8' "F#+"#)*+!I"&",! % '
The histopathological examination
$ !% $ revealed hyperkeratosis and acanthosis of
Tuberculosis caused by Mycobacterium the ectocervix along with endocervicitis.
tuberculosis is a prevalent infectious The mononuclear inflammatory infiltrate
disease in resource challenged countries consisted of lymphocytes, histiocytes and
such as India. Tuberculosis of the female macrophages. At places, well formed
genital tract accounts for a minority of epithelioid cell granulomas were seen
cases. 90% of cases are those of women in along with Langhans and foreign body
the reproductive age group. The most giant cell formation. A provisional
commonly affected regions are the diagnosis of granulomatous cervicitis was
endometrium and fallopian tubes [1],[3]. made and ancillary investigations were
Tuberculosis of the cervix includes 5-24% carried out to find the cause. The AFB
of genital tract tuberculosis and 0.1% - stain did not reveal any bacilli.
0.65% of all tuberculosis cases3.
Tuberculosis can have a varied The patient was investigated for other
presentation and can even mimic veneral diseases which also simulate
malignancy on clinical presentation. The granulomatous pathology such as
differential diagnosis of tuberculosis has Chlamydia trachomatis, Neisseria
to be kept in mind whenever an atypical gonorrhea, Trichomonas vaginalis, and
presentation is encountered in clinical Herpes simplex virus. All these
practice. The following are 2 cases which investigations did not point towards any of
presented on clinical examination as the veneral diseases mentioned above.
malignancy, which turned out to be cases HIV, HBsAg and HCV tests were non
of cervical tuberculosis on the basis of reactive. A hormone profile was normal.
histopathological reports. ESR was 135 mm after one hour.

# The Mantoux test was positive. On the

& diagnosed as that of cervical tuberculosis
A 58 year old female presented with
complaints of difficulty in urination,
defaecation and something coming out of
the vaginal os for one month. Her physical
examination revealed cystocele and
rectocele with third degree descent of the
uterus. There was a decubitus ulcer on the
anterior lip of the cervix and congestion
on the posterior lip.
The routine laboratory investigations were
within normal limits. The chest skiagram
was unremarkable. An ultrasound
examination revealed a retroverted uterus
which was normal in shape and size. The
endometrial thickness was 5mm. A
basis of the histological reports and other
ancillary investigations, the case was
and the patient was initiated on anti
tubercular treatment. A repeat biopsy three
months later was negative for
granulomatous pathology. Surgical
treatment for prolapse was followed up.
'
A 38 year old female presented in the
gynaecology outpatient with the complaint
of menometrorrhagia. Her pelvic
examination revealed a friable papillary
growth on the cervix. Pap smear revealed
a mixed inflammatory infiltrate along with
atypical cells of uncertain origin
(ASCUS). A punch biopsy was taken for
diagnostic confirmation. The clinical

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differentials included neoplastic and viral
aetiologies. The most common presenting symptoms
are infertility, amennorhoea and
The histopathological examination constitutional symptoms. Menstrual
revealed endocervicitis with well formed irregularities, procidentia with decubitus
epithelioid cell granulomas along with ulcer and abdominal pain may also be
Langhans giant cell formation and present. A history of contact with a
caseation necrosis [Table/Fig 1]. A tuberculosis index case is
provisional diagnosis of tuberculosis of variable[1],[4],[5]. HIV positive patients
the cervix was made. AFB stain did not are at an increased risk of developing
reveal any bacilli. Further investigations these lesions [6].
were done to rule out any comorbid
conditions. A re- biopsy of the growth was The affected cervix may be hypertrophied,
done and the tissue was sent for tubercular ulcerated or may show friable papillary
polymerase reaction (TB-pcr), which was growth which mimicks carcinoma. The
positive for Mycobacterium tuberculosis. pap smear may reveal dyskaryosis and
may also show the evidence of
The patient was started on antitubercular granulomatous inflammation and giant cell
therapy. The growth regressed after four formation. A punch biopsy is required for
months. A repeat biopsy revealed the histopathological evaluation. Chronic
absence of granulomatous inflammation. inflammation with the formation of
Till the last follow up, the patient was caseating or non caseating granulomas is
symptom free. evident in most of the cases. Staining for
AFB and culture of the tissue is the gold
[Table/Fig 1]: Photomicrograph of section standard for diagnosis. Ancillary
of endocervix ( ) showing caseating investigations must be carried out to
granulomas and Langhans giant cells ( ) exclude other causes of granulomatous
admist chronic inflammatory infiltrate. inflammation such as Chlamydia
(H&E 400 X). trachomatis, Neisseria gonorrhea,
Trichomonas vaginalis and Herpes
simplex. Other rare causes of
granulomatous cervicitis include
schistosoma, amoebiasis, brucella,
tularemia, sarcoidosis and foreign body
reactions. ESR, Mantoux test and X ray
chest also support the diagnosis.
Molecular probes are sensitive but not
specific [3],[7].

Some studies have emphasized that the

presence of typical granulomas are
sufficient for the diagnosis of tuberculosis
if other causes of granulomatous cervicitis
are excluded [3],[6].

( % $ Pelvic organs including cervix are usually

In 2005, the World Health Organization
reported a prevalence of 20 million cases
of tuberculosis worldwide. Out of these 15
million cases reside in developing
countries [1]. The average prevalence of
tuberculosis in India is estimated to be
5.05 per thousand and the average annual
incidence of smear positive cases is 84 per
100,00 [2].
secondarily affected by haematogenous
spread following primary pulmonary
infection. The cervix gets involved by
direct extension or lymphatic spread.
Rarely may tuberculosis be contracted
primarily as a sexually transmitted disease
[1],[3]. The lesion should respond to six
months of standard therapy. Serial biopsy

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 specimens usually confirm a therapeutic <!= 0 > 4? >
response [3]. ( 2
2 #!" 8 !""& ??
Sometimes tuberculosis may coexist with !&)+G,
an underlying uterine malignancy, which <*= B ; ? A 1
should be thoroughly investigated [7]. A > . 1 B 2
higher incidence has been reported from ? > > (
? $2 !"") ,&@ *(
areas which are endemic for tuberculosis
<&= : A / 1 3 1 1 ?
and where HIV prevalence is more. A high A ?
index of suspicion for tuberculosis is 2 ;
justified while dealing with cervical !""I &)%*'(*F"+!
lesions in females of the reproductive age <I= > ; > > 1
> 1 B 1
group. ( ?
> 2
The cases described in this report are both #FFI > F*%I'(#,G+)
HIV negative. The patient in the first case <,= . - > 7
is postmenopausal, which is a rare (
? A
presentation. It is thus emphasized, that 1 2 !""! $
tuberculosis of cervix must be included in G)%#'(,!+*
the differential diagnoses, especially in the <G= 8 > 7 8 > +4 1
endemic areas. 8 8 1 8B / ?
/ (
? > - 1
) $ !"", ,%!'( G,+)"
<#= J -
2 2
!""I ) %#'( *! N *I

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