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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 5  |  Issue : 3  |  Page : 357-359

Genital tuberculosis: Unusual presentations


Department of Obstetrics and Gynecology, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, India

Date of Web Publication13-Feb-2017

Correspondence Address:
Sneha Shree
Department of Obstetrics and Gynecology, University College of Medical Sciences and Guru Teg Bahadur Hospital, H-51/12, West Jyotinagar, Shahdara, Delhi 110094
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.1016/j.ijmyco.2016.06.017

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  Abstract 


Genital tract tuberculosis is usually secondary to extragenital tuberculosis. The upper genital tract is usually involved; involvement of cervix and vulva is very uncommon. We present two such rare cases of vulval and cervical tuberculosis diagnosed on histopathology and treated with antitubercular chemotherapy.

Keywords: Cervix, Colposcopy, Female genital tract, Tuberculosis, Vulva


How to cite this article:
Gupta B, Shree S, Rajaram S, Goel N. Genital tuberculosis: Unusual presentations. Int J Mycobacteriol 2016;5:357-9

How to cite this URL:
Gupta B, Shree S, Rajaram S, Goel N. Genital tuberculosis: Unusual presentations. Int J Mycobacteriol [serial online] 2016 [cited 2021 Apr 20];5:357-9. Available from: https://www.ijmyco.org/text.asp?2016/5/3/357/200081




  Case reports Top


Case 1

A 40-year-old multiparous patient presented to us with the complaint of excessive itching in the perineum. On examination, she was of average built. General physical examination was normal with no palpable lymph nodes. Systemic examination did not reveal any abnormality. On examination, multiple excoriation marks were seen on the labia with erosion. Bimanual examination showed a normal-sized, anteverted, mobile uterus with no palpable adnexal masses or forniceal tenderness. Per rectum examination also revealed no abnormality. She underwent vulvoscopy and colposcopy. White patches on the labia majora and minora were seen (right>left) along with a few raised areas. Mild acetowhitening of cervix was seen but visual inspection with Lugol's iodine was negative. Papanicolaou smear was reported as negative for intraepithelial lesion or malignancy. Multiple directed labial biopsies were taken, which reported giant cell granulomas.

Case 2

A 60-year-old multiparous postmenopausal woman came to us with discharge per vaginum. The patient was of thin build and general physical examination was essentially normal; there were no palpable inguinal or supraclavicular lymph nodes. Local examination showed an unhealthy, congested cervix with ectropion. Bimanual pelvic examination revealed a normal sized retroverted, mobile uterus with no palpable adnexal mass or forniceal tenderness. Papanicolaou smear was inflammatory. On colposcopy, multiple areas of increased vascularity with acetowhite areas were seen. Visual inspection with Lugol's iodine was negative; directed cervical biopsies were taken, which revealed granulomatous inflammation ([Figure 1]).
Figure 1: Granulomatous inflammation on histopathology of cervical biopsy.

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The spouses of the patients were examined and no evidence for tubercular lesion was found. Antibody tests for human immunodeficiency virus (HIV) were negative in both patients. Both patients were treated with antitubercular chemotherapy with four drugs (isoniazid, rifampicin, pyrazinamide, and ethambutol) for 6 months.

Ethical considerations

Informed written consent was taken from both patients regarding the submission of cases as well as photographs. Ethical clearance was obtained from the Ethics Committee of University College of Medical Sciences and Guru Tegh Bahadur Hospital, Delhi, India.


  Discussion Top


Genital tract tuberculosis (TB) is usually secondary to extragenital TB. The upper genital tract is usually involved in genital TB, affecting  Fallopian tube More Detailss and endometrium. Cervical TB is uncommon, responsible for 0.1–0.65% of all cases of TB and 5–24% of genital tract TB [1]. TB of the vulva is even rarer and is seen in only 1–2% of cases of genital tract TB [2].

The incidence of genital TB is higher in developing countries. With the rising incidence of HIV infection, associated genital TB incidence is on the rise. Approximately 9% of all extrapulmonary TB cases are genital tract TB [3].

Fallopian tubes and ovaries are commonly involved, with other pelvic organs such as the vagina, vulva, myometrium, and cervix less commonly so. Spread to these sites is either by hematogenous, lymphatic dissemination, or direct extension. About half of the patients are asymptomatic. Besides constitutional symptoms, symptomatic cases usually present with abnormal vaginal bleeding, menstrual irregularities, abdominal pain, and local ulcers [4].

TB of the uterine cervix may present as papillary or vegetative growth with or without ulceration mimicking invasive cervical cancer. Agrawal et al. [5] and Elkattan et al. [6] reported two such cases of cervical TB that simulated cervical carcinoma.

Vulval TB was first described by Bates and Rucker [7]. Lesions are usually ulcerative. Kaur and colleagues [8] described such a case of vulval TB that presented as an ulcerative lesion. A hypertrophic variety of vulval TB is very uncommon; such a case was described by Tiwari et al. [9]. Suppuration and ulceration of the inguinal lymph nodes may occur.

The diagnosis of the cervical and vulvovaginal TB is usually made by histological examination of cervical and vulvovaginal biopsy specimens, respectively. Isolation of mycobacterium is the gold standard for diagnosis. Presence of typical granulomata is sufficient for diagnosis. Culture may not be very useful as about a third of cases turn out to be negative. Also, staining for acid-fast bacilli may be unyielding [10]. Newer diagnostic tests such as enzyme-linked immunosorbent assay and polymerase chain reaction may help in earlier detection of TB. Concomitant HIV testing should also be done, especially in areas with high HIV prevalence. There should be a high index of suspicion of genital TB in women from areas where HIV and TB are common. One such case was reported by Lamba et al. [11] where a patient who attended a genitourinary clinic was found to have cervical TB in association with HIV infection.

The differential diagnosis for granulomatous disease of the cervix includes amoebiasis, schistosomiasis,  Brucellosis More Details, tularaemia, sarcoidosis, and foreign body reaction [12]. Few ulcerative lesions may simulate invasive cervical cancer. A vulval tubercular ulcer may also be misdiagnosed as syphilis or chancroid, and rarely as vulval malignancy.


  Conclusion Top


Genital tract TB should always be considered as the differential diagnosis of suspicious genital lesions, particularly in developing countries where TB is so common. The aim of reporting these cases is to highlight atypical presentations of TB. Our cases bring forth the uncommon features of a very common disease, highlighting the unending ways TB can manifest.


  Conflicts of interest Top


The authors have no conflicts of interest to declare.



 
  References Top

1.
J.R. Carter, Unusual presentations of genital tract tuberculosis, Int. J. Gynaecol. Obstet. 33 (1990) 171–176.  Back to cited text no. 1
    
2.
F. Akhlaghi, A.B. Hamedi, Postmenopausal tuberculosis of the cervix, vagina and vulva, Int. J. Gynaecol. Obstet. 3 (2004) 1–3.  Back to cited text no. 2
    
3.
S.K. Sharma, A. Mohan, Extra pulmonary tuberculosis, Indian J. Med. Res. 120 (2004) 316–353.  Back to cited text no. 3
    
4.
S. Singh, V. Gupta, S. Modi, et al, Tuberculosis of uterine cervix: a report of two cases with variable clinical presentation, Trop. Doct. 40 (2010) 125–126.  Back to cited text no. 4
    
5.
S. Agrawal, M. Madan, N. Leekha, et al, A rare case of cervical tuberculosis simulating carcinoma cervix: a case report, Cases J. 2 (2009) 161.  Back to cited text no. 5
    
6.
E. Elkattan, M. Abd El Badei, H. Hettow, et al, Tuberculous cervicitis mimicking cancer cervix: a case study, Middle East Fert. Soc. J. 19 (2014) 75–77.  Back to cited text no. 6
    
7.
R. Bates, M.P. Rucker, Virginia Med. Monthly 71 (1944) 199.  Back to cited text no. 7
    
8.
T. Kaur, S. Dhawan, A. Aggarwal, et al, Vulval tuberculosis, J. Obstet. Gynecol. India 62 (2012) 450–451.  Back to cited text no. 8
    
9.
P. Tiwari, D.K. Pal, D. Moulik, et al, Hypertrophic tuberculosis of vulva – a rare presentation of tuberculosis, Indian J. Tuberc. 57 (2010) 95–97.  Back to cited text no. 9
    
10.
R. Kalyani, S. Sheela, M. Rajini, Cytological diagnosis of tuberculous cervicitis: a case report with review of literature, J. Cytol. 29 (2012) 86–88.  Back to cited text no. 10
    
11.
H. Lamba, M. Byrne, R. Goldin, et al, Tuberculosis of the cervix: case presentation and a review of the literature, Sex. Transm. Infect. 78 (2002) 62–63.  Back to cited text no. 11
    
12.
A.B. Koller, Granulomatous lesions of the cervix uteri in black patients, South Afr. Med. J. 49 (1975) 1228–1232.  Back to cited text no. 12
    


    Figures

  [Figure 1]


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