|Year : 2014 | Volume
| Issue : 1 | Page : 48-50
An ulcerated mass in the cervix: Carcinoma or tuberculosis
Deepa Kapoor1, Prerna Kapoor2, Niraj Kumari3, Narendra Krishnani3, Pallavi Aga4
1 Department of Gynecology and Obstetrics, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
2 Department of Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
3 Department of Pathology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
4 Department of Radiology, King George's Medical University, Lucknow, Uttar Pradesh, India
|Date of Web Publication||7-Apr-2014|
Department of Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow - 226 014, Uttar Pradesh
Tubercular involvement of the cervix is rare and the clinical presentation often simulates that of cervical carcinoma leading to misdiagnosis. We report here the case of a 31-year-old female who presented with secondary amenorrhea, post-coital vaginal bleeding, lower abdominal pain, and mild low-grade fever. Cervical examination revealed an unhealthy cervix, with an irregular, ulcerated mass that bled on touch, raising the suspicion of a cervical malignancy. Histopathology of the cervical biopsy revealed typical necrotizing granulomas and also confirmed the presence of acid fast bacilli in the specimen. Antitubercular therapy was started and the patient responded, with rapid amelioration of symptoms and regression of the cervical mass. Tuberculosis of the cervix is an uncommonly encountered entity and presentation may closely resemble that of cervical carcinoma. Tuberculosis should be considered an important differential diagnosis of a malignant-appearing lesion of the cervix, especially in areas where it is endemic.
Keywords: Carcinoma, cervix, genital tuberculosis
|How to cite this article:|
Kapoor D, Kapoor P, Kumari N, Krishnani N, Aga P. An ulcerated mass in the cervix: Carcinoma or tuberculosis. Trop J Med Res 2014;17:48-50
| Introduction|| |
Although the incidence of tuberculosis has dramatically declined in the West, it is still common in the developing world. Tubercular involvement of the female genital tract most frequently affects the upper genital tract (endometrium and Fallopian tube More Detailss), while involvement of the cervix is extremely rare. , It is important to highlight such anecdotal cases, as clinical presentation of tuberculosis of the cervix often closely resembles that of cervical carcinoma, leading to misdiagnosis. A high index of suspicion is essential, especially in areas where tuberculosis is endemic, as these cases are potentially curable with medical therapy. As most cases are females in the reproductive age group, timely diagnosis and institution of treatment can help restore a normal and fertile lifespan. We report a case that clinically appeared as a malignant cervical mass, but on the basis of a histopathological report, was diagnosed as cervical tuberculosis.
| Case Report|| |
A 31-year-old married female, who presented with secondary amenorrhea and post-coital vaginal bleeding since the last seven to ten years, respectively. She also complained of intermittent, episodic lower abdominal pain and mild low-grade fever off and on. There was no history of any vaginal discharge, cough, hemoptysis or weight loss. She had never been treated for tuberculosis in the past, nor was there any history of tuberculosis in her family. General physical examination was normal except for a mild pallor; small (1.5-2 cm), bilateral, non-tender, non-matted lymph nodes, which were palpable in the left cervical and bilateral axillary regions. The chest and cardiovascular systems were unremarkable.
Per-speculum examination revealed a slightly dilated cervix, with an irregular, ulcerated, friable looking mass that bled on touch, raising a suspicion of cervical malignancy [Figure 1], panel a]. The uterus was normal in size, anteverted, with bilateral clear fornices. A per rectal examination was normal and there was no evidence of inguinal lymphadenopathy.
|Figure 1: Per speculum examination revealed a dilated cervix, with an irregular, ulcerated mass that bled on touch, raising the suspicion of cervical malignancy (Panel a). Significant regression noted at follow-up (Panel b)|
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Routine lab testing revealed a hemoglobin (HB) of 10.1 g/dl, Thin-layer chromatography (TLC) of 7.800/mm 3 , while the erythrocyte sedimentation rate (ESR) was 35 mm in the first hour; and the rest of the blood chemistry was normal. There was no evidence of pulmonary tuberculosis on the chest X-ray. An ultrasound examination of the pelvis revealed a bulky uterus, measuring 89 × 28 mm, with a normal myometrial texture and a focal rounded mass (31 × 31 mm) in the fundal region, suggestive of a fibroid. Magnetic resonance imaging (MRI) demonstrated a heterogeneous, predominantly hypointense mass in the cervix [Figure 2], white bold arrow] along with pelvic lymphadenopathy and a posterior wall fibroid.
A cervical Pap smear More Details demonstrated smear-sheets of superficial and intermediate squamous epithelial cells along with occasional clusters of endocervical cells, without any evidence of malignancy. A biopsy done from the cervical mass revealed multiple confluent focally necrotizing granulomas composed of lymphocytes, plasma cells, epithelioid histiocytes and Langhans-type giant cells. Ziehl-Neelsen (ZN) staining confirmed the presence of acid fast bacilli [Figure 3].
|Figure 2: MRI imaging (Sagittal T2 and T2 STIR image) showing a heterogeneous, predominantly hypointense mass (white bold arrow) involving the cervix. A posterior wall fibroid was also visualized|
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|Figure 3: Photomicrograph shows stratified squamous and endocervical lining epithelium, with the subepithelial tissue beneath the squamous lining showing multiple epithelioid cell granulomas. (Hematoxylin and eosin stain, (Panel a) and visible Acid fast bacilli (Panel b, arrow)|
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On the basis of the histopathology report, a final diagnosis of cervical tuberculosis was established. The patient was started on antitubercular therapy under the Directly Observed Therapy (DOT category 1) regime as per the Revised National Tuberculosis Control Program (RNTCP) guidelines (isoniazid, ethambutol, rifampin, and pyrazinamide). The post-coital bleeding ameliorated within a month of institution of therapy and at the last follow up of five months, the cervical mass had significantly regressed [Figure 1], panel b].
| Discussion|| |
Although pulmonary tuberculosis is the most common clinical manifestation of tuberculosis, it can involve any organ. Genital Tuberculosis, although uncommon in the West, is a major socioeconomic burden and represents an important cause of infertility among Indian women in the reproductive age group. It usually involves the fallopian tubes followed in order of frequency by the endometrium and ovaries. , Tuberculosis of cervix is, however, extremely uncommon and accounts for <1% of all cases of tuberculosis. ,, Genital involvement is usually secondary to extragenital tuberculosis, which in most cases arises from a pulmonary focus. Spread of infection to the cervix is either by the hematogenous or lymphatic route or by direct local extension from tuberculous salpingitis and endometritis. Rarely, cervical involvement may occur via sexual contact with a partner who has underlying genitourinary tuberculosis. ,,, Our case did not have any other obvious extragenital focus of infection, and the husband also did not have any obvious urogenital manifestation of tuberculosis.
Similar to our case, genital tract tuberculosis usually presents with abnormal vaginal bleeding or vaginal discharge, irregularities of menstruation, abdominal pain, fever, and constitutional symptoms, including anorexia and weight loss. ,,, The clinical presentation along with the presence of papillary, military, ulcerative, exophytic or endophytic growths in the cervix often simulate invasive cervical cancer. ,, The diagnosis, as happened in our case, is often established by histopathology of a cervical biopsy specimen. Although documenting the presence of acid fast bacilli (AFB) is considered the gold standard for diagnosis, nearly 30% of the cases may be culture negative. Therefore, demonstration of typical necrotizing granulomas is considered sufficient for the diagnosis, especially in the presence of a primary tubercular focus. However, in areas where tuberculosis is highly endemic, it may not be uncommon to demonstrate AFB in the histopathology, indicating a high mycobacterium burden, as shown in our case and also previously reported. 
Anti-tubercular therapy for at least six months is recommended in these cases and a close clinical follow-up to monitor the cervical mass/growth, is mandatory in all cases. However, as most patients with cervical tuberculosis have associated tubercular involvement of the endometrium and fallopian tubes, successful spontaneous conception following anti-tubercular therapy is not guaranteed. This underscores the importance of an early diagnosis (when the disease may still be localized) and timely institution of therapy. In our case too, the patient is on regular follow-up and conception is still awaited.
| Conclusion|| |
Although rare, tuberculosis should be considered an important differential diagnosis of a malignant-appearing lesion of the cervix. A high index of suspicion is important, especially in areas where tuberculosis is endemic. As many of these patients are young and in the reproductive age group, timely diagnosis and treatment are important.
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[Figure 1], [Figure 2], [Figure 3]