Case Report | Open Access | Full Text

¹Resident Physician, Department of Gynecology and Obstetrics, at Ibno Rochd University Hospital, Casablanca, Morocco
²Professor in the Department of Gynecology and Obstetrics at the Ibno Rochd University Hospital in Casablanca, Morocco

*Corresponding author: Tawil Fatima Ezahraa, Resident Physician, Department of Gynecology and Obstetrics, Ibno Rochd University Hospital, Casablanca, Morocco

Summary

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Tuberculosis is a public health problem, particularly in developing countries. Pulmonary bacillary tuberculosis is the most common form of tuberculosis, while genital tuberculosis is rare and underdiagnosed. We report here a case of endometrial tuberculosis. The study involved a 64-year-old female patient undergoing treatment for breast cancer, consulting her gynecologist because of abnormal uterine bleeding. Pelvic ultrasound revealed thickening of the endometrium. This was suggestive of endometrial cancer. Pathological examination of endometrial curettage specimens showed granulomatous endometritis suggestive of follicular tuberculosis. The outcome was favorable with anti-tuberculosis treatment.
Abbreviations: EET: Endometrial Tuberculosis

Introduction

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Endometrial tuberculosis (EET) is an infection of the reproductive system caused by Mycobacterium tuberculosis, mainly transmitted hematogenously to the endometrium Worldwide, the incidence of tuberculosis is steadily declining. Although the prevalence of BER is relatively low, it has a significant impact on women's reproductive health, and is recognized as one of the main causes of infertility in affected populations. It is estimated that in countries with a high prevalence of tuberculosis, between 5% and 16% of infertility cases are associated with genital tuberculosis, with ETB being the predominant subtype. ETB directly alters the function and structure of the endometrium, leading to menstrual irregularities, infertility and other reproductive health problems.

Patient and observation

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64-year-old patient, nulligravida, postmenopausal for 19 years, with pathological history, followed for neo of the right breast since 2016 treated by right mastectomy with homolateral axillary curage, the patient received chemotherapy + radiotherapy + hormone therapy. The onset dated back to six months before the consultation with abnormal uterine bleeding without other associated signs, with pelvic ultrasound aspect in favor of an endometrial thickening measuring 13mm maximum thickness. A neoplastic cause was suspected, justifying a biopsy curettage of the endometrium with anatomopathological examination. This examination revealed: fragments of endometrial mucosa; site of granulomatous inflammation, made up of epithelioid and giant cells, often organized in confluent follicles, the glands are regular, atrophic or discreetly proliferative.
Granulomatous endometritis of tuberculous origin was suspected.
Tuberculosis treatment (2 months of a combination of ethambutol, rifampicin, isoniazid and pyrazinamide and 4 months of rifampicin combined with isoniazid), the evolution was favourable with and endometrial tuberculosis were described.

Discussion

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The incidence of genital tuberculosis is unknown, as many cases remain undiagnosed due to the frequency of latent and inapparent forms [1]. It is always secondary, following either hematogenous dissemination from an initial tuberculosis focus initial focus of tuberculosis, with initial involvement of the fallopian tubes (100% of cases) resulting in salpingitis, from which the infection progresses to the other genital organs; or lymphatic contamination from pelvic lymph nodes; rare cases secondary to direct inoculation by venereal contact have been reported by Weinstein [2,3]. It predominantly affects young, genitally active women [2,4]. Our patient was 64 years old at the time of diagnosis. Chau [5]. and Houda [1]. have also published similar cases. Tuberculous endometritis in post-menopausal women is often isolated, with no tubal involvement, unlike that in young women, which is often associated with tuberculous salpingitis [5].
After menopause, a clinical sign that may occur in endometrial tuberculosis is bleeding and, less frequently, pyometra. The important differential diagnosis in this age group is endometrial cancer [6-8]. In a report of two cases of women presenting with postmenopausal bleeding in Brazil, hysteroscopy revealed a exuberant focal thickening of the endometrium suggesting hyperplasia, subsequently confirming the diagnosis of tuberculosis by pathological examination [9]. In addition to pathology, techniques such as mycobacterial culture and polymerase chain reaction (PCR) can be used for diagnosis [10]. The polymerase chain reaction of tuberculosis is the most sensitive indicator for the diagnosis of urogenital tuberculosis, followed by biopsy and culture [10].
In this patient, given her age and clinical presentation, the first diagnosis suggested was a neoplastic cause. This explains why this examination was not carried out in the patient. However, it should be emphasized that associations of tumor and endometrial tuberculosis have been described.
Treatment is currently well codified and based on daily administration of isoniazid and rifampicin for 6 months, combined with pyrazinamide and ethambutol for the first 2 months [11]. Clinical and paraclinical monitoring is carried out regularly throughout the course of treatment.

Conclusion

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Tuberculosis remains common but rarely manifests as endometrial involvement. Young women of low socio-economic status, consulting for infertility, are most concerned. However, it is important to be aware of the possibility of tuberculosis when pelvic symptoms are present, regardless of age, and to carry out examinations to help make the diagnosis.

References

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