THIEME

Case Report 409

Endometrial Tuberculosis: Hysteroscopic

Findings of a Clinical Case
Tuberculose endometrial: Achados histeroscópicos de
um caso clínico
Daniela Siqueira Prado1 Lucas Félix Cardoso1 Raimundo Dantas de Maria Júnior1
Guilherme Machado de Santana Israel Santos Marcelo1 Marcela Sampaio Lima1 Ângela Maria Silva1
1

1 Department of Medicine, Universidade Federal de Sergipe, Aracaju, Address for correspondence Lucas Félix Cardoso, Rua Cláudio Batista,
SE, Brazil s/n, 49060-108, Cidade Nova, Aracaju, SE Brazil
Rev Bras Ginecol Obstet 2019;41:409–411. (e-mail: glucasfc@gmail.com).

Abstract Endometrial tuberculosis is a rare diagnosis in the postmenopausal period, and it can
mimic a carcinoma. The present article describes the case of a 54-year-old female
patient with weight loss, abdominal pain, and ascites. An ultrasonography showed
endometrial thickening, and a video hysteroscopy revealed a uterine cavity with
formations with cotton aspect covering the entire endometrial surface and the tubal
Keywords ostia. An anatomopathological evaluation diagnosed endometrial tuberculosis. The
► urogenital treatment was with a standardized therapeutic scheme (ethambutol, isoniazid,
tuberculosis pyrazinamide and rifampicin), and the patient evolved with clinical improvement
► endometrium and normal uterine cavity at hysteroscopy. Considering the lack of pathognomonic
► hysteroscopy hysteroscopic findings of the disorder, it is important to disclose the images of the case.

Resumo A tuberculose endometrial é um diagnóstico raro na pós-menopausa e pode mimetizar

um carcinoma. O presente artigo descreve o caso de uma paciente de 54 anos com
perda de peso, dor abdominal e ascite. A ultrassonografia mostrou espessamento
endometrial, e a histeroscopia por vídeo revelou uma cavidade uterina com formações
que apresentavam aspecto de algodão cobrindo toda a superfície endometrial e os
Palavras-chave óstios tubários. Uma avaliação anatomopatológica diagnosticou tuberculose endome-
► tuberculose trial. O tratamento foi com esquema terapêutico padronizado (etambutol, isoniazida,
urogenital pirazinamida e rifampicina), e a paciente evoluiu com melhora clínica e cavidade
► endométrio uterina normal na histeroscopia. Considerando a falta de achados histeroscópicos
► histeroscopia patognomônicos do distúrbio, é importante divulgar as imagens do caso.

Introduction
node tuberculosis and pleural tuberculosis.2 Clinical or sub-
Tuberculosis is a major public health problem worldwide. clinical urogenital tuberculosis affects between 4.7 and
About 10.4 million people developed tuberculosis in 2015.1 10.4% of the individuals who have pulmonary tuberculo-
Urogenital tuberculosis is the 3rd most common manifesta- sis.3,4 Genital tuberculosis usually occurs secondary to tu-
tion of extrapulmonary tuberculosis, preceded by lymph berculosis in other sites (primarily, the lungs). The spread is
generally through haematogenous or lymphatic routes.5,6
Lucas Félix Cardoso's ORCID is https://orcid.org/0000-0002- The diagnosis of genital tuberculosis in the female genital
4546-4453. tract should be considered in patients with risk factors such

received DOI https://doi.org/ Copyright © 2019 by Thieme Revinter

December 13, 2018 10.1055/s-0039-1692634. Publicações Ltda, Rio de Janeiro, Brazil
accepted ISSN 0100-7203.
May 16, 2019
410 Endometrial Tuberculosis Prado et al.

as personal or family history of tuberculosis, people who live the entire endometrial surface and the tubal ostia, (►Fig. 1)
or have traveled to endemic areas, people with clinical and one endocervical polyp. The endometrial biopsy showed
infertility, pelvic or abdominal pain, and menstrual disor- a granulomatous endometritis with numerous epithelioid
ders.5 The majority (75%) of women with genital tuberculosis granulomas, multinucleated giant cells, and caseous necrosis
are in the reproductive age (between 20 and 45 years old), (►Fig. 2). There were no malignant cells in the sample. The
and the detection of this disease in the postmenopausal Ziehl-Neelsen staining revealed some acid-fast bacilli in
phase is rare.7 In the female genital tract, the development of areas of caseous necrosis, confirming histological findings
this disease occurs, most commonly, in the uterine tubes compatible with endometrial tuberculosis (►Fig. 2). Fungus
(90% of the cases). The infection may progress to the endo- research was also performed by periodic acid-Schiff (PAS)
metrium and to the ovaries. Vulvar or vaginal tuberculosis is and Grocott staining, which was negative. The cervical lesion
exceedingly rare.8,9 was consistent with endocervical polyp, associated with
Endometrial tuberculosis is a rare finding, with few epithelioid granulomas and multinucleated giant cells on
studies in the literature, most of them from underdeveloped its axis, but in a lesser degree than that observed in the
countries, which have the highest prevalence of tuberculosis endometrium. There were no atypias.
in the population.9,10 The patient was discharged from the hospital, and was
Hysteroscopy, as a diagnostic technique, is an important referred to the outpatient clinic of the infectology service of the
tool in the detection of endometrial tuberculosis.9,11 The HU-UFS, being treated by a standardized therapeutic scheme,
most common findings described by the use of this technique using a combined fixed dose consisting of the following drugs:
are a thin endometrial thickness with dirty appearance, rifampicin (150mg), isoniazid (75mg), pyrazinamide (400mg),
irregular and pale endometrium with whitish deposits and ethambutol (275mg) for 2 months, as well as rifampicin
linked to the surface, presence of intrauterine adhesions, (150mg) and isoniazid (75mg) for another 4 months.5,12 The
and a small and slightly expandable uterine cavity.8–11 patient evolved with pain relief, regression of the ascites, and
Considering the lack of a specific hysteroscopic finding of weight gain. After the treatment, a new hysteroscopy was
endometrial tuberculosis and the low frequency of this performed and it was verified that the uterine cavity was
disorder, particularly in the postmenopausal period, it is normal (►Fig. 3). A microscopic examination revealed a
important to disclose the images of the described case. residual inflammatory reaction with lymphocytes and histio-
cytes, and only one poorly formed granuloma below the
endometrial epithelium. No necrosis or bacilli were found.
Case Description
A 54 year-old woman, married, menopause at 50 years old,
Discussion
with a previous history of 1 vaginal delivery and 1 abortion, was
admitted to the Hospital Universitário of the Universidade The clinical findings of postmenopausal endometrial tuber-
Federal do Sergipe (HU-UFS, in the Portuguese acronym), culosis are nonspecific and difficult to diagnose in patients
presenting with low intensity abdominal pain, mainly located with no history of pulmonary tuberculosis or risk factors.
in the left iliac fossa, with weight loss, and no other associated Thus, in the present case, hysteroscopy was essential for the
symptoms. A total abdominal ultrasonography showed the diagnosis. In a retrospective study, with 67 cases of women in
presence of ascites, and a transvaginal ultrasonography showed infertility research who were diagnosed with endometrial
centered and homogeneous endometrial echo with a thickness tuberculosis, the presence of whitish deposits was verified,
of 14.2 mm. No alteration was evidenced by a chest X-ray. similar to those detected in the present study.10,13,14
A diagnostic hysteroscopy was performed and revealed a After menopause, a clinical sign that can occur in endo-
uterine cavity with formations with cotton aspect covering metrial tuberculosis is bleeding, and, less frequently, pyo-
metra. The important differential diagnosis in this age group
is endometrial cancer.14–16 In a report of two cases of women
with postmenopausal bleeding in Brazil, the hysteroscopy
found exuberant focal endometrial thickening suggesting
hyperplasia, subsequently confirming the diagnosis of tu-
berculosis by the anatomopathological examination.10 In
addition to pathology, techniques such as culture of myco-
bacteria and polymerase chain reaction (PCR) can be used for
the diagnosis.17 Polymerase chain reaction for tuberculosis is
the most sensitive indicator for the diagnosis of urogenital
tuberculosis, followed by biopsy and culture.17
In another report of hysteroscopies of three cases of
patients with endometrial tuberculosis in India, the aspect
of “starry sky” was verified in one of them, by the application of
a technique that uses methylene blue. This dye is not absorbed
by the caseous tuberculous deposit, but it is absorbed by the
Fig. 1 Uterine cavity with formations with cotton aspect. normal surrounding endometrium. Thus, the unstained

Rev Bras Ginecol Obstet Vol. 41 No. 6/2019

 Endometrial Tuberculosis Prado et al. 411

Fig. 2 Endometrium. On the left, multiple granulomas in the endometrial stroma (hematoxylin and eosin stain, 20x). In the middle, granulomas
with multinucleated giant cells (hematoxylin and eosin stain, 40x). On the right, some acid-fast bacilli in areas of caseous necrosis
(Ziehl-Neelsen,100x).

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breck P, Denes E. Tuberculose utérine post-ménopausique. J Gynecol
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Rev Bras Ginecol Obstet Vol. 41 No. 6/2019