Primary tuberculosis of cervix mimicking carcinoma: A rare case.

This is a rare case of a 35 year old multiparous lady with complaints of postcoital bleeding and foul smelling discharge for 3 months. On per speculum examination, a large irregular friable growth was seen which used to bleed on touch. A provisional diagnosis of carcinoma cervix was made, but the cervical biopsy revealed granulomatous inflammation with caseation, consistent with the diagnosis of cervical tuberculosis. The patient responded well to 6 months of antitubercular treatment. Hence, tuberculosis should be kept as a differential diagnosis of carcinoma cervix.

INTRODUCTION

Tuberculosis (TB) of cervix is a rare finding. Spread to cervix is either by hematogenous, lymphatic dissemination or by direct extension. The lesion on the cervix can be either exophytic, ulcerative although interstitial and endocervical polypoid form may also occur. Patients with cervical TB present with persistent offensive discharge, abnormal bleeding, malaise and other constitutional symptoms of infection. Diagnosis depends upon the isolation of tubercle bacilli on microscopy and histopathology. A rare case of cervical TB is being reported, which was suspected as malignant lesion on clinical examination, but turned out to be a case of cervical TB on the basis of histopathological report.

CASE REPORT

The case we present here is about a 35-year-old multiparous female who presented to the outpatient department with the chief complaints of foul smelling discharge and lower abdominal pain for last 3 months. She also complained of postcoital bleeding and dyspareunia, but there were no menstrual complaints. There was no history of fever or weight loss. She had no previous history of TB in self or any family member. On examination, there was no lymphadenopathy and the systemic examination was unremarkable. On per speculum examination, cervix was replaced by a large irregular and friable growth which bled on touch. On bimanual examination, same growth was felt. Uterus was anteverted, normal in size and mobile. Bilateral fornices were free and nontender. Bilateral parametrium were free of any growth or nodularity.

Paps smear showed inflammation. Colposcopic examination showed an irregular growth with increased vascularity without any acetowhite or iodine negative areas [Figures 1 and 2]. Based on the clinical and colposcopic findings, a provisional diagnosis of cervical cancer was made. A punch biopsy was taken from the growth, which showed multiple epithelioid granulomas with caseation, consistent with the diagnosis of TB [Figure 3]. A chest X-ray was normal and HIV-1 and 2 were negative. Patient was started on four antitubercular drugs: Isoniazid, ethambutol, rifampicin and pyrazinamide. Patient responded well to 9 months of antitubercular therapy (ATT) and is doing fine.

Figure 1

Colposcopy showing an irregular friable growth with increased vascularity

Figure 2

Colposcopy showing uptake of iodine by the cervical growth

Figure 3

Histopathology of cervical biopsy showing multiple epithelioid granulomas and caseation

DISCUSSION

Genital organs most frequently affected include fallopian tubes (95-100%), endometrium (50-60%), and ovaries (20-30%).[1] TB of the cervix is rare and accounts for 0.1-0.65% of all cases of TB and 5-24% of genital tract TB.[2] Symptomatic genital tract TB usually presents with abnormal vaginal bleeding, menstrual irregularities, abdominal pain, and constitutional symptoms. TB of cervix can present with various ways and may at times even mimic malignancy.[34] The diagnosis of cervical TB is difficult clinically as the symptoms and physical examination usually do not give clues to the disease. Pelvic organs are infected from a primary focus, usually the chest, by hematogenous spread.[1] Lymphatic spread or direct infection is the mode of involvement of cervix. Often the primary lesion would be healed at presentation. The macroscopic findings of cervical TB can vary. There may be a hypertrophy of the cervix or show friable papillary or vegetative growth simulating invasive cervical cancer.[456] The diagnosis of cervical TB is usually made by histological examination of a cervical punch biopsy specimen. Microscopically, there will be an extensive chronic inflammation with the presence of caseating or noncaseating granulomas in most of the cases. Staining with acid-fast bacilli may not reveal the organisms. Isolation of the mycobacterium is the gold standard for diagnosis. Up to one-third of the patients can be culture negative.[7] Molecular probes may be more sensitive than culture, but also have reduced specificity. Hence, presence of granulomas is considered sufficient enough to make a diagnosis after excluding other causes of granulomatous cervicitis. The other rare causes of granulomatous cervicitis are schistosomiasis, brucellosis, tularemia, sarcoidosis or a foreign body reaction.[7] In general, the patients respond to 6-9 months of standard ATT. Regular follow-up of patient will be necessary to examine the lesion, which would be marker to access response to treatment, which can be confirmed by histopathological examination of serial biopsies.

CONCLUSION

Hence in women with an abnormal cervical appearance, there should be a high index of suspicion of TB, especially from areas where TB is common.