Coexistent tubercular cervicitis with tuberculosis of the little finger: an unusual presentation

Abstract

Dear Editors, Tuberculosis (TB) of the uterine cervix accounts for 0.1–0.65% of all cases of TB and 5–24% of genital tract TB [1]. Its gross appearance gives the Wrst impression of a cervical cancer. A 20-year-old nulliparous lady reported to us with a 1-year history of postcoital bleeding, secondary amenorrhoea 8 months and swollen little Wnger since 6 months duration. She had low grade fever with more than 5 kg weight loss and loss of appetite over the last 6 months; and denied any cough or abdominal pain or treatment for pulmonary kochs. General systemic examination was normal except nodular swollen little Wnger of the left hand with excoriation on the surface (Fig. 1). She had undergone excision of the nodule previously which recurred 4 months back. The swelling was inXamed, hyperaemic with ulceration and non-pulsatile. X-ray was normal with no bony involvement. External genitalia appeared normal; on per speculum examination, the entire ectocervix was replaced by an ulcerative growth of 4 £ 4 cm with copious mucopurulent discharge mimicking cancer cervix (Figs. 2, 3). On pervaginal and rectal examination, the growth was friable, bled on touch; there was bilateral parametrial inWltration just short of pelvic wall. The Wndings were conWrmed on contrast MRI. Uterus was normal in size with free rectal mucosa. Biopsy from the cervix and little Wnger both showed multiple epithelioid cell granulomas with langhans type of giant cells and focal necrosis along with diVuse inWltration by lymphocytes and other chronic inXammatory cells. AFB smear showed 3–4 bacilli/10 hpf. The features were suggestive of tuberculosis. No malignant cells were seen. Chest X-ray was normal; HIV and VDRL for both partners was non-reactive; urine was negative for acid fast bacilli (AFB). Antitubercular therapy was started using Directly Observed Treatment Strategy (DOTS) according to Category I as per WHO guideline for genital TB using rifampicin, isoniazid, pyrizinamide and ethambutol for 2 months followed by rifampicin and isoniazid for 4 months. At present, the patient has completed 4-month therapy with signiWcant reduction in postcoital bleeding and cervical lesion along with decrease in swelling of the Wnger. A number of cases of tubercular cervicitis have been reported in literature with vaginal bleeding, menstrual irregularities, abdominal pain, and constitutional symptoms. Our patient presented with secondary amenorrhoea and postcoital bleeding. Genital TB is generally secondary to haematogenous spread from lungs. The spread to cervix is usually lymphatic from other pelvic organs or by direct extension. Macroscopically, tubercular cervicitis simulates invasive cervical cancer [2], and microscopic presence of caseating granulomas needs exclusion from other causes of granulomatous cervicitis (amoebiasis, schistosomiasis, brucellosis, tularaemia, sarcoidosis, and foreign body reaction) [3]. Biopsy cervix is essential for conWrmation of diagnosis although isolation of mycobacterium is the gold standard. Some patients can have infertility and secondary amenorrhoea due to tubal and endometrial involvement [4, 5]. Secondary amenorrhoea in our patient suggests endometrial involvement and Asherman syndrome. Rarely tubercular cervicitis can also present as postmenopausal bleeding [6]. Coexistent cranial tuberculomas and tuberculosis of the N. Gupta · A. Bahadur · D. Deka · S. Mittal Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi, India