Postmenopausal genital tract tuberculosis in the United States: A report of two cases

March 1, 2014

When a postmenopausal patient presents with signs and symptoms of a gynecologic malignancy, one should consider the possibility of genital tuberculosis in women who have immigrated to the United States.

Dr. Moore is assistant clinical professor, site director and program director, Louisiana State University School of Medicine Ob/Gyn Residency Program, Baton Rouge.

Dr. Dupuy is general faculty, Louisiana State University School of Medicine Ob/Gyn Residency Program, Baton Rouge.

Neither author has a conflcit of interest to disclose with respect to the content of this article.

 

Acknowledgements

The authors thank Sarah Buzhardt, MD, for her assistance with writing this paper, and Miriam Busch, MD, for her assistance with editing and pursuing publication. They also thank Louise McLaughlin at Louisiana State University Health Sciences Center for her assistance with the literature review.

Female genital tuberculosis (FGT) is rare in the United States. Of the 9951 reported cases of tuberculosis in 2012, fewer than 1% affected the genital tract and the majority occurred in foreign-born people.1 Postmenopausal women account for fewer than 10% of cases of genital tuberculosis, and it is estimated that tuberculosis of the cervix accounts for 0.1%–0.65% of tuberculosis cases worldwide.2-4 Our review of the US medical literature revealed only 1 case report of tuberculosis of the cervix diagnosed in the United States and reported in the medical literature in the past 37 years.5

Genital tract tuberculosis can involve the internal pelvic organs as well as the external genital organs. Usually the fallopian tubes are involved, followed sequentially by the uterus, ovaries, cervix, vagina, and vulva.

Pelvic tuberculosis is an entity with a variety of presentations and is often mistaken for ovarian carcinoma.6 The most common findings are pelvic mass (90%), elevated CA-125 (90%), ascites (60%), sterility (45%–55%), pelvic pain (45%–50%), poor general health (26%), and menstrual disturbances (10%–20%).2,7

Cervical tuberculosis frequently mimics cervical carcinoma. Presentation may include postcoital bleeding, vaginal discharge, pelvic pain, mucopurulent cervicitis, ulcerations, and exophytic lesions.

Here we describe 2 cases of FGT in postmenopausal women. The first case involves the pelvic organs and mimics ovarian carcinoma. The second involves the cervix and presents as suspected cervical carcinoma.

Case 1

A postmenopausal 52-year-old Vietnamese woman who emigrated from Vietnam to Louisiana in 1996 presented to the emergency department (ED) with complaints of abdominal pain, nausea, and bright red blood in her stools. Her last menstrual period had been approximately 5 years before. She was afebrile and in no distress. Abdominal examination revealed a soft, non-tender, non-distended abdomen with bowel sounds present. Stool was heme-negative. She was prescribed dicyclomine for abdominal pain and promethazine for nausea and sent home.

She presented to the ED 2 months later with complaints of worsening abdominal pain and nausea unrelieved by medication. She reported daily bowel movements and denied bloody stools. Her abdomen was slightly distended with normal bowel sounds. Computed tomography scan of the abdomen and pelvis revealed ascites, omental thickening with nodularity in the mesentery, possible involvement of the capsule of the liver, thickening of the wall of the small bowel, and mildly distended small bowel loops. There was a 3-cm cystic lesion in the right lower abdomen, an enlarged lymph node in the right lower quadrant, and a 3.7-cm solid lesion in the left adnexa. She was referred to a gynecology clinic because of suspicion for ovarian cancer.

 

When evaluated in the gynecology clinic 4 days later, the woman described a “heavy feeling” in her lower abdomen. She denied fever, chills, night sweats, or weight loss. On examination, a small vesicular exophytic lesion of the cervix was noted, and an approximately 4- x 5-cm left adnexal mass was palpated. A Pap smear was negative. No cervical biopsies were performed. Transvaginal ultrasound showed a normal uterus, cervix, vagina, and bladder. The right ovary measured 3 x 2.8 x 2.1 cm. In the left adnexa was a 7.3 x 6.5 x 3.5-cm complex cystic mass with a “fishnet” appearance. Our gynecologic oncology consultant recommended an exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, and staging. CA-125 was 235 U/mL. Preoperative chest x-ray revealed normal heart and lungs.

Exploratory laparotomy revealed extensive intra-abdominal adhesions with apparent miliary process
(Figure 1).  

Approximately 3 liters of ascites were evacuated and lysis of adhesions was performed. The pelvic mass was unresectable. An omentectomy was performed and the tissue sent to pathology for frozen section, which revealed a granulomatous process. Multiple biopsies of the lesions were taken throughout the abdominal cavity for fungal and mycobacterial studies.

Postoperatively the patient was placed in respiratory isolation and a tuberculin skin test (PPD) was reported positive at 20 mm. Three sputum samples were collected daily; the first 2 were positive for acid-fast bacilli (AFB). While the patient was in the hospital, antimicrobial therapy consisting of rifampin,
isoniazid (INH), pyrazinamide, and ethambutol (RIPE) was initiated. Abdominal cultures were positive for Mycobacterium tuberculosis per DNA probe and sputum cultures were positive for Mycobacterium avium complex, also per DNA probe. Drug susceptibility testing indicated INH-resistant M. tuberculosis. The patients’ drug regimen consisted of 2 months of RIPE therapy, then INH and rifampin, then moxifloxacin, rifampin, and ethambutol for 9 months. At 1 year, the patient was doing well with no symptoms of abdominal pain. Her ascites had resolved and her pelvic exam was normal.

Case 2

A 47-year-old postmenopausal Filipino woman who had been living in the United States for approximately 18 months presented to the ED with a 1-year history of vaginal spotting, vaginal discharge, lower abdominal pain, dyspareunia, postcoital bleeding, and absence of menses for 2 years prior to the vaginal bleeding. Initial evaluation included a gynecologic exam, cervical cultures, and an appointment at a gynecology clinic.

Pelvic examination at the time of the initial gynecology visit revealed a friable, hemorrhagic, nodular cervix, with a purulent exudate (Figure 2).

The adnexa were mildly tender and indurated bilaterally. Results of cervical cultures done at the ED visit were positive for Chlamydia trachomatis. Impression was severe mucopurulent cervicitis secondary to chlamydia, and therapy with azithromycin was initiated. On follow-up visit, there was no improvement in either reported symptomatology or the appearance of the cervix. Multiple cervical biopsies were obtained to rule out squamous cell carcinoma of the cervix. (A previous Pap smear was unsatisfactory.)

 

Biopsy results reported chronic granulomatous cervicitis with acute ulceration. AFB and periodic acid-Schiff stains were negative. Because the biopsy was suggestive of tuberculosis, the patient returned for further biopsies to obtain smears and cultures for AFB and fungi, and to perform a PPD and chest radiograph. Further history was obtained. She denied cough, anorexia, night sweats, or weight loss, but did reveal that her sister had died years earlier in the Philippines while being treated for tuberculosis.

The PPD was positive at >10 mm, and the chest radiograph revealed patchy, abnormal opacities in the lung apices bilaterally with a 0.7-cm calcified coin lesion just above the left hemi-diaphragm. M. tuberculosis was isolated from the cervical biopsy per DNA probe and susceptibility testing indicated susceptibility to RIPE and streptomycin. Fungal studies were negative.

The patient was referred to the East Baton Rouge Parish tuberculosis clinic for treatment and begun on RIPE therapy. Three months after initiation of therapy, she returned to our clinic for follow-up. She was asymptomatic and speculum examination revealed a healed atrophic cervix consistent with her postmenopausal status and resolution of her disease.

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Discussion

The female genital tract can be infected with acid-fast or tuberculous bacilli by hematogenous spread, lymphatic spread, direct extension, and through sexual contact.² Hematogenous spread begins in the lungs, with the primary lung infection usually undetectable by the time diagnosis of the genital tract occurs. Lymphatic spread occurs from the alimentary tract when milk contaminated with bovine tubercle bacillus is consumed. Direct extension occurs from intraperitoneal surfaces and begins by invading the mucosa of the fallopian tubes.2 Tubercle bacilli may also be sexually transmitted by a partner with tuberculous epididymitis or infected sputum.3

Infertility is one of the most common presenting signs of FGT. In a postmenopausal woman, signs and symptoms can be similar to those found in gynecologic malignancies. Involvement of the fallopian tubes occurs in 90%–100% of cases of genital tract tuberculosis. The uterus is affected in 50%–60% of cases, followed by the ovaries (20%–30%), cervix (5%–15%), and vagina/vulva (1%).2 If the cervix is involved, 70%–75% of cases have involvement of the endocervix, whereas only 25% of cases involve the exocervix.

Sporadic case reports of cervical tuberculosis from endemic areas of the world exist in both foreign and US literature.¹ However, we have been unable to find reports of cervical tuberculosis diagnosed in the United States and reported in the US literature in more than 3 decades.

FGT is not easily diagnosed because tissue is required to identify granulomatous disease and to perform cultures. The Mantoux test, or PPD, has a sensitivity of only 55% in women with FGT; therefore it is not a reliable indicator of disease.8 Treatment of FGT is medical, usually RIPE therapy.

When a postmenopausal patient presents with signs and symptoms of a gynecologic malignancy, one should consider FGT in women who have immigrated to the United States. Sixty-three percent of TB cases in the United States involve foreign-born individuals. The top 4 countries of origin are Mexico (20.9%), the Philippines (12.3%), India (8.5%), and Vietnam (7.2%).1 A thorough history should be obtained in cases of suspected FGT, including a personal history of disease, close contact with infected persons, travel, and former residence in endemic regions. It is important to consider FGT as a cause of gynecologic disease because the primary treatment for FGT is medical, not surgical.

 

References

1. Centers for Disease Control and Prevention. Trends in Tuberculosis-United States, 2013. MMWR. 2012;62(11):201–205.

2. Schaefer G. Female genital tuberculosis. Clin Obstet Gynecol. 1976;19:223–239.

3. Lamba H, Byrne M, Goldin R, Jenkins C. Tuberculosis of the cervix: Case presentation and review of the literature. Sex Transm Inf. 2002;78:62–63.

4. Danforth W. Tuberculosis of the cervix. Ann Surg. 1937;106:407–412.

5. Shobin D, Sall S, Pellman C. Genitourinary tuberculosis simulating cervical carcinoma. J Reprod Med. 1976;17:305–308.

6. Karsidag A, Api O, Dansuk R, et al. Pelvic tuberculosis simulating advanced ovarian malignancy. J Pelvic Surg. 2006;12(4):207–211.

7. Xi X, Shuang L, Dan W, et al. Diagnostic dilemma of abdominopelvic tuberculosis: A series of 20 cases. J Cancer Res Clin Oncol. 2010;136:1839–1844.

8. Raut VS, Mahashur AA, Sheth SS. The Mantoux test in the diagnosis of genital tuberculosis in women. Int J Gynecol Obstet. 2001;72:165–169.