Three in a row: A case series of cervical tuberculosis*

By Angelynn Santos Sianghio, MD and Elizabeth Espino-Strebel, MD, FPOGS, FSGOP

Department of Obstetrics and Gynecology, San Juan de Dios Educational Foundation, Inc. Hospital

ABSTRACT

Cases of cervical lesions have been rising steadily in the past decades. From inflammation to carcinogenesis, the
cervix is never really spared of disease. In the presence of a cervical mass, malignancy is always a consideration. In
this paper, we present three cases of cervical tuberculosis that were diagnosed in a tertiary private hospital in Pasay
City. Women in their 3rd and 4th decade of life presenting with post coital spotting, copious vaginal discharge and
amenorrhea were examined: The cervix was converted to a nodular friable mass, with extension to the fornices. On
rectovaginal exam, both parametria were nodular but free from the pelvic sidewall. The primary consideration was
a probable cervical carcinoma stage IIB. On tissue biopsy and further testing, cervical tuberculosis was confirmed.
Quadruple anti-Koch’s therapy was initiated, to which clearing of the cervix with decrease discharge was noted.

Keywords: Anti-Koch’s therapy, Cervical tuberculosis, Epitheloid cells, Langhan’s Giant cells, Tuberculosis (TB)

INTRODUCTION CASE REPORTS

T
uberculosis has long been plaguing men. It was once Case A
regarded as a fatal “wasting” disease until in 1952 A 39 year-old G2P2 (2002) came in due to post
when it was deemed curable with the discovery of coital spotting of 4 months’ duration, associated with
anti-Koch’s medications. copious non-foul smelling vaginal secretions. She denies
In the 17th century, genital tract tuberculosis hypogastric pain, night sweats, chronic cough, weight loss
comprised 7.7% of all cases of TB, which increased to or anorexia. Previous pap smears were normal. She had
5-25% in the 20th century.2 no previous surgery or exposure to radiation. There was
According to the Global tuberculosis report of 2016, no history of malignancy in the family. Patient recounts
6.1 million new TB cases were detected and reported exposure to pulmonary TB 3 years prior, as primary
worldwide; 18% of which came from the Philippines. caregiver to her 6 year-old son. The patient was regularly
Thirty-four percent of the 324,000 newly diagnosed menstruating and denies intermenstrual spotting or
cases of tuberculosis comprised of females, 87% percent prolonged vaginal bleeding. Two pregnancies were carried
belonging to the child-bearing age.1 to term and delivered vaginally with no complications.
TB mimics carcinoma, and is often times misdiagnosed There was no period of infertility recounted. The patient
as a malignancy. Meticulous history-taking and a high had her coitarche at 24 years old with one lifetime sexual
index of suspicion, coupled with laboratory examinations, partner. She had been married for 12 years to a 47 year-old
aid in distinguishing between these two disease entities. seaman and claims to have oral contraceptive pill intake for
Among women, genital tuberculosis represents 5-10% 3 years. The patient is a non-smoker and a non-alcoholic
of non-pulmonary cases. Cervical involvement appears in beverage drinker. On physical examination, BMI was 24.
5-15% of all cases of female genital tuberculosis, i.e. 0.1- There were no palpable preauricular and supraclavicular
0.65% of all tuberculosis cases.3 Low detection rates and lymph nodes. No neck masses noted. Chest and abdomen
report rates for cervical tuberculosis may be due to its were unremarkable, no enlarged or palpable inguinal
asymptomatic period. The value of ultrasound and other lymph nodes. On pelvic examination, there was a nodular
imaging studies are limited, compared to histopathologic hyperaemic periturethral mass measuring 1x1cm, which
diagnosis. does not bleed easily. The cervix was converted to a
nodular friable mass measuring 4x6cm with extension
to the fornix from 1 o’clock to 7 o’ clock position. On
rectovaginal examination, both parametria were nodular
but free. Patient underwent cervical biopsy with a
*Third Place, Philippine Obstetrical and Gynecological Society primary consideration of cervical carcinoma stage IIB.
(Foundation), Inc. (POGS) Interesting Case Paper Contest, September Upon histopathologic confirmation, caseous necrosis and
13, 2018, 3rd Floor Assembly Hall, POGS Building Langhan giant cells were noted, supporting the diagnosis
Volume 42, Number 5, PJOG September-October 2018 41
of tuberculosis. Further work ups were done, revealing Repeat TVS revealed a normal sized uterus with rich color
multiple ill-defined densities with nodular configuration flow, thin endometrium of 0.29cm, a pelvoabdominal
in both upper lungs in chest radiographic studies. Sputum mass measuring 8.96x4.10x8.79cm with 1.58cm cystic
was positive for AFB at 9-10/100hpf. Urine and stool anechoic thin walled area at the posterior end, within
were negative for AFB. Transvaginal ultrasound revealed the mass is seemingly normal ovarian tissue. Cervical
a hyperechoic cervical lesion with some hypoechoicities biopsy was done and a referral to a gyne-oncologist
looking like moth-eaten structures. The endometrium was made. Plans of trachelorrhapy was disclosed.
was thin with probable calcifications. The ovaries were Histopathology then revealed chronic granulomatous
normal. She was started on quadruple anti-Koch’s therapy inflammation consistent with tuberculosis. Slide review
and responded well to treatment. Upon follow up after was concurrent with previous reading: acute on chronic
8 months of medication, the patient reports general granulomatous endocervicitis with microglandular
improvement of well-being, with resolution of postcoital hyperplasia and focal langhan’s giant cells favour a
vaginal bleeding and vaginal discharge. There was likewise tuberculous process. Chest Xray, as well as urine, stool
a decrease in size of the cervical and periurethral masses. and sputum AFB were unremarkable. Patient was
She was advised continuation of treatment for 9 months, referred to infectious disease specialist where quadruple
with interval repeat chest x-rays, pelvic examination, therapy was started. Monthly pelvic examination
transvaginal ultrasound, as well as colposcopic examination revealed gradual resolution of the fungating mass as
to monitor response and effectivity of treatment. well as the vaginal discharge. She now claims to whitish
non foul smelling discharge. Continuation of treatment
Case B was advised and partner work up was recommended.
A 28 year-old nulligravid came in due to yellowish Patient is desirous of pregnancy and was advised TVS
discharge of two years duration however no consult after 6 months of medications to monitor effectivity of
done until one year prior when an increase in the treatment, confirm the possibility of conceiving, and
amount of discharge, now foul smelling with associated predict the probability of ectopic pregnancy. TVS showed
post coital spotting was noted. Initial consult at a a normal sized uterus with secretory endometrium,
private clinic revealed unremarkable pelvic findings. normal right ovary with corpus luteum, normal left ovary,
Ultrasound revealed normal anteverted uterus with left adnexal mass 6.68x3.24x5.86cm and right adnexal
proliferative endometrium of bilateral ovaries not mass 8.71x3.53x8.62cm, both with low to medium level
delineated with note of two masses, both with complex echoes within. She was then advised to delay pregnancy
echoes tender to probe manipulation and with irregular until complete resolution of symptoms and further work
shape and bordered by fluid. The left mass measured ups be made. Future plans include diagnostic laparoscopy
7.31x6.37x3.78cm while the right mass measured for persistent disease or hysteroscopy once complete
7.59x7.90x5.96cm. A cystic anechoic thick walled mass resolution was noted.
with cogwheel pattern at the superior pole of the right
pelvoabdominal mass measuring 2.82x2.74x2.34cm. Case C
Antibiotics for PID was started. Repeat TVS yielded A 37 year-old G3P3 (3003) consulted the outpatient
same results hence a primary consideration of cervical department for amenorrhea of 5 years duration. The
carcinoma with metastasis was inferred: She was patient sought initial consult at a tertiary hospital where
referred to a gynecologic oncologist, however, was lost she was given Progesterone pills however no response
to follow up. Six months prior, consult at our institution was noted. Two months prior, clear watery, non-foul
due to persistence of copious foul smelling discharge, smelling discharge was noted. She denies weight loss or
now with associated increasing abdominal girth and post loss of appetite, no vaginal spotting, no dyspareunia or
coital spotting. No exposure to tuberculosis was noted on post coital bleeding. The patient noted copious yellowish,
family members or partner. Coitarche was at 22 years old foul smelling discharge one month prior, using 2 fully
with 2 sexual partners. No menstrual irregularities noted. soaked panty liners per day. No consult done until one day
On examination, BMI was 24, no anterior neck masses prior when post coital spotting was noted. All pregnancies
seen. A firm moveable infraumbilical mass measuring were carried to term and delivered vaginally without
10x7cm was noted. The a note of nodular fungating mass complications by a traditional birth attendant at home.
at the ectocervix; internal examination revealed that the On physical examination, BMI was equivalent to 18.2.
cervix was converted to a 2x2cm nodular fungating mass No neck masses or palpable lymphnodes noted. Chest,
with smooth fornices noted. Rectovaginal examination lung, and abdomen examinations were unremarkable.
noted the left parametria was smooth, shortened but Pelvic exam revealed the cervix was friable with a 3x2cm
free while the right parametria was smooth and pliable. fungating mass that easily bleeds with purulent yellowish

42 Volume 42, Number 5, PJOG September-October 2018

discharge. On internal examination the cervix was parous uterus and adnexa. Cervical biopsy was submitted: note
and nodular, the uterus was asymmetrically enlarged to of necrotic tissue with acute and chronic inflammation,
12 weeks size and adnexa were unremarkable. Cervical no malignancy was described. Histopathologic diagnosis
carcinoma stage IIb was considered, the patient was was non-caseating granulomatous inflammation, consider
advised of a series of medical and surgical management. tuberculosis as primary cause. Patient was advised further
Transvaginal sonography revealed unremarkable cervix, work up however was lost to follow up.

A B
Figure 3. (A) Epitheloid Cells, Histologic Hallmark for tuberculo-
sis and (B) Caseous Necrosis

Figure 1. Pre-treatment (A) Periurethral mass (B) Cervical lesion

of Case A

Figure 1. And Post-treatment of quadruple anti-Koch’s

medications for 8 months (C) Periurethral mass (D) Cervix

Figure 2. Langhan’s Giant Cell, a walling-off response to avoid

metastasis with spindle cells and fibroblasts B
Volume 42, Number 5, PJOG September-October 2018 43
 C F
Figure 4. Cervical lesions of Case B from (A) diagnosis, (B) 1st
month of treatment, (C) 2nd month, (D) 3rd month, (E) 4th
month, (F) 5th month

Figure 5. Cervical lesion of Case C, showing nodular fungating

mass with copious yellow discharge

D DISCUSSION
Three cases of cervical masses in women in the 3rd to
4 decade of life were described. Usual symptoms were
th

postcoital vaginal spotting, increased vaginal discharge of

months duration and amenorrhea. Initial impression of
carcinoma was highly entertained. According to Domingo
and Dy Echo, cervical cancer is the second most common
malignancy and is the most common cancer-related
mortality among Filipino women.1 Cervical vaccines,
colposcopic examinations, Pap Smears and contraceptives
have been advocated, yet detection and development of
the disease remains to be insurgent. The nature of the
cervical malignancy remains elusive. Reported new cases
of cervical cancer last 2005 was 7,277, with reported
deaths of 3,807.1 The census for cervical cancer steadily
increases with a high mortality rate attributed to its
late detection, and the treatment being inaccessible,
unavailable, or unaffordable.1 Most cases are diagnosed at
E stages III or IV. Risk factors for cervical malignancy include:
44 Volume 42, Number 5, PJOG September-October 2018
smoking, oral contraceptive use, fertility, early coitarche, said that the prevalence of genital tuberculosis is directly
and socioeconomic status. In order to diagnose cervical proportional to the incidence of pulmonary tuberculosis
cancer, a tissue biopsy is required and is the first step. All in an area.5 The infrequency of reported cases may be
three cases were advised of possible results and has been attributed to the low detection rates due to the relatively
counselled of the economic burden of what lies ahead. asymptomatic or non-specific signs and symptoms of the
Histopathology results revealed chronic granulomatous extrapulmonary disease.
inflammation suggestive of tuberculous infection. Because Of the two cases with further work up, only case A
of the rarity of a cervical TB, the difference in management appears to have disseminated tuberculosis. Symptomatic
between TB and malignancy, and the huge impact of a genital TB usually presents with menstrual irregularities,
misdiagnosis of cervical carcinoma, slide reviews were abnormal vaginal bleeding, and abdominal pain. However,
requested. Slide review of the gynecologic oncologist was some cases are asymptomatic and are discovered
in concurrence with the primary interpretation, chronic accidentally during investigations of infertility.4 There are
granulomatous inflammation with surface ulcerations, postulations of hormone dependence of the disease as
suppuration, caseation necrosis and focal Langhan’s to the discovery is mostly among females of reproductive
giant cells, findings which favour a tuberculous process. age.7
Microsections revealed inflamed vascularized fibrous The genital organs are usually infected from
tissue fragments with surface ulcerations. The tissue the primary chest lesion by hematogenous spread.4
sections contain considerable number of inflammatory Mycobacterium tuberculosis is a slow growing bacterium
cells, predominantly chronic type admixed with neutrophils and only doubles its population every 18-24 hours. This
towards the surface and along the areas of necrosis. slow doubling time partly explains the chronic nature of
Occasional Epitheloid histiocytes were appreciated as well the disease and may allow dissemination before acute
as multinucleated giant Langhan’s cells. symptoms develop.5
The detection of typical granulomata is sufficient Having presented with nonspecific symptoms of
for diagnosis if the other causes of granulomatous postcoital vaginal spotting and increased vaginal discharge,
cervicitis, such as amoebiasis, schistomiasis, brucellosis, in a patient with a cervical mass, the patients were
tularemia, sarcoidosis, and foreign body reaction, have initially assessed to have cervical carcinoma stage IIB. As
been excluded.4 Other typical features of tuberculosis tuberculosis of the cervix will be mistaken for carcinoma
on histology are epitheloid cell granulomas with or far more frequently than it will be confused with any
without Langhan’s giant cells. Caseating necrosis is rare other disease, the necessity for immediate differentiation
in specimens from the genital tract5 however, tissues is apparent.2
obtained from all patients exhibited caseous necrosis According to Danforth, 4 types of tuberculous
alongside the pathognomonic Epitheloid histiocytes. invasion are distinguished: the ulcerative, the miliary, the
Further investigation were done to case A and B papillary, and the interstitial. The ulcerative type is usually
to determine the presence of pulmonary and other characterized by a single lesion, the edges of which are
extrapulmonary sites of tuberculosis. Findings for Case A: rather well defined. The ulcer bleeds easily on contact
Chest x-ray revealed multiple ill-defined densities in both but less so in instances of carcinoma. The papillary type
upper lungs, sputum AFB revealed 1-9 AFB/ 100 visual may be confused with carcinoma which it may resemble
fields, urine and stool were negative. closely. In the miliary variety, the cervix is enlarged and
Case B had inconspicuous results. small miliary tubercles may be visible on the surface.
Pelvic tuberculosis is a frequent cause of chronic pelvic The interstitial type appears first in the substance of the
inflammation and infertility.1 The macroscopic appearance cervix, forming a nodule which may become necrotic. The
of tuberculous cervicitis mimics cervical cancer.4 The necrotic material may be discharged, leaving a cavity.2
discovery and the pestilence of the disease remains elusive. In all three cases, the appearance of the cervix may be
It has been estimated that 5-13% of the cases of classified as papillary due to its nodularity and immediate
pulmonary TB develop a genital infection. The fallopian bleeding upon manipulation or contact, thus explaining
tubes are affected most commonly (90%), followed by symptoms. During primary infection, organisms may
the endometrium (50%), and the ovaries (10-30%). The spread systemically and at a later stage, may be activated
cervix is rarely involved and accounts for 5-24% of cases at a genital stage. The most common mode of transmission
of genital tract tuberculosis.4 Tuberculosis of the cervix to the genital tract is through hematogenous spread from
accounts 0.1-0.65% of all cases of tuberculosis, and 5-24% pulmonary or other sites of tuberculosis.4
of all genital tract TB.6 In the Philippines, there are only 4 Until the advent of anti-Koch’s therapy, hysterectomy
reported cases of genital tract tuberculosis. As previously with bilateral salpingooophorectomy had been the
mentioned, TB is endemic in the Philippines, and it is practice.

Volume 42, Number 5, PJOG September-October 2018 45

 Cervical tuberculosis generally responds to standard need of surgery except in cases resistant to medical
anti-tuberculous treatment. A four drug regimen consisting treatment. Indications for surgical intervention include:
of isoniazid, ethambutol, rifampicin and pyrazinamide is (1) persistence of or progression of the disease despite
used for the first two months, followed by triple or dual adequate medical treatment; (2) suggested residual large
therapy, with its dosing computed in relation to the body tubo-ovarian abscess; (3) positive endometrial culture/
mass index. The total duration of treatment should be six histology and recurrence of pain or bleeding after 9
months to a year. Excellent cure rates are reported for all months of medical treatment; and (4) fistulas that fail to
of the standard treatment regimens.5 heal. Surgical therapy usually consists of total abdominal
A lesion on the cervix provides a marker to assess hysterectomy and bilateral salpingooophorectomy and
response to therapy. Serial colposcopic observation should be performed at least 6 weeks after initiation of
and histopathological examination by punch specimens antituberculous therapy, because antimicrobial treatment
can confirm therapeutic response.8,10 Case A had visible facilitates the surgical procedure and reduces the risk of
decrease in the periurethral mass as well as clearing of perioperative complications.8
the cervix and improvement of discharge. Case B had This case series emphasizes that though uncommon,
improvement in the discharge as well as clearing of the tuberculosis is an important differential diagnosis for
cervix. Hysterosalpingography is an important diagnostic cervical lesions with nonspecific signs and symptoms,
tool especially for patients who are in the child bearing especially in countries with high prevalence of the disease.
age. This may be particular for Case B, on the other hand,
Case A is not desirous of pregnancy hence no future plans SUMMARY
for hysterosalpingography is contemplated.
The immediate differentiation of tuberculosis Tuberculosis is a pervasive disease yet symptoms remain
and carcinoma is beneficial and prudent as to plan vague and nonspecific. Cervical tuberculosis represents
for treatment. Irradiation of a tuberculous cervix is a a minority of cases; its rarity is an important differential
therapeutic error, as the insertion of radium preceded diagnosis with patients who presents with suspicious looking
by the necessary dilatation of the cervix predisposes cervix and nonspecific symptoms. Mainstay treatment
to the spreading of the disease.2 There is rarely any remains to be anti-Koch’s medications.

REFERENCES

1. Global tuberculosis report 2016. World Health Organization. 7. Nabi U, Fozia U, Nafees M, Khurshid N. Tuberculosis of the cervix;
a Rare Clinical Entity. International Journal of Pathology. 2012;
2. Danforth W. Tuberculosis of the cervix. Annals of Surgery. Sept 1937. 10(1):41-43.

3. Pintos-Pascual I, Roque-Rojas F, Castro-Sanchez M, Bellas- 8. Guo WJ, Shieh G-R, and Chen S-L. Female extrapulmonary genital
Menendrez C, Millia-Perez R, Ramos-Martinez A. Cervix tuberculosis tuberculosis: feull term deliveries after 4 years of follow up. Taiwan
stimulating cancer. Rev Esp Quimioter. 2017; 30(2):138-139 J Obstet Gynecol. 2010; 49(1):105-108.

4. Yang C-T, Lee Y-H, Hsu G-J. Tuberculosis of the uterine cervix. 9. Singhal SR, Chaudhry P, and Nanda S. Genital tuberculosis with
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5. Botha MH, Van der Merwe FH. Female genital tuberculosis. SA 10. Afzali,N. Ahmadi, F, Akhabari, F. Various hysterosalpingography
Fam Pract. 2008; 50 (5):12-16. findings of female genital tuberculosis: a case series. Iran J
Reproductive Medicine. 2013; 11(6):519-524.
6. Lamba H, Byrne M, Goldin R, Jenkins C. Tuberculosis of the cervix:
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46 Volume 42, Number 5, PJOG September-October 2018