Tuberculosis in adenomyosis: Common conditions with rare coexistence

Adenomyosis is a common health problem in the middle-aged women, characterized by the presence of endometrial glands and stroma in the myometrium. It is considered as an extension of basal endometrium and the glands are of proliferative type. These foci can be involved by any of the diseases affecting the orthotopic endometrium, including hyperplasia and adenocarcinoma. Genital tract tuberculosis in women commonly involves fallopian tubes, endometrium, and cervix. Involvement of the myometrium is very rare. Tuberculous lesions in the foci of adenomyosis are very rare and only few cases have been described in the English literature.[] CASE REPORT A 45-year-old lady, P 2 L 2 presented with vague abdominal symptoms and menorrhagia of 1-year duration. She had undergone appendicectomy 1 year earlier with similar complaints. Gynecological examination and ultrasonography suggested adenomyosis. Total abdominal hysterectomy with salpingo ophorectomy was done and the specimen was sent for hisopathological examination. Gross The uterus measured 10 × 5 × 4 cm with increased endomyometrial thickness. The myometrium was trabeculated and had tiny cysts [Figure 1] and yellowish areas. Both fallopian tubes and right ovary were grossly unremarkable. Microscopy Multiple sections from endomyometrium showed epithelioid cell granulomas in the endometrium [Figure 2a]. The myometrium showed extensive adenomyosis [Figure 2b] and numerous areas of necrosis with epithelioid cell granulomas in most of these sites of adenomyosis [Figure 3a, 3b]. At places, these entire foci were replaced by chronic necrotising granulomatous infection and fibrosis giving an impression of granuloma in the myometrium. Stain for acid-fast bacilli (AFB) showed a few AFB. A diagnosis of extensive adenomyosis with tuberculosis was made. Sections from fallopian tube also showed an occasional epithelioid cell granuloma in the mucosa. The patient was treated with antituberculous drugs and is doing fine after 6-months follow-up.

Adenomyosis is characterized by the presence of endometrial glands and stroma in the myometrium. It is considered as the extension of basal endometrium. The glands seen are usually of proliferative type, may be dilated giving rise to tiny cysts. The diseases affecting the orthotopic endometrium, including hyperplasia and adenocarcinoma can affect these foci. Common sites of tuberculous infection of the genital tract in women are fallopian tube and endometrium. Myometrial involvement is rare. In endometrial tuberculosis, the granulomas are usually seen in the functional endometrium, which is shed during menstruation. Involvement of basal endometrium is uncommon and seen only in very severe cases. Adenomyosis is extension of basal endometrium into the myometrium; hence, tuberculous involvement of adenomyotic foci is very rare. The present case showed extensive adenomyosis in the uterus with most of these foci showing granulomatous inflammation extending into the adjacent myometrium. In some of these foci, the endometrial tissue was totally replaced by necrotising granulomas surrounded by fibrosis. The endometrial tissue in adenomyosis is not shed like the mucosal endometrium and the infection in these sites can remain for a long time and spread to the adjacent myometrium. This can be a hidden site from where the infection can spread to various other sites in the body and result in miliary spread, if the immunity is lowered. It is important to identify these cases and treat to prevent further spread. There are only few cases that are described in the English literature. The earliest case described was in 1948 by De soldenhoff R. who reported a case,[] followed by Howell[] in 1953, Mcintosh & Richmond[] in 1959 who described three cases each, and Rickford[] in 1955 reported a case of adenomyosis with tuberculosis in a 48-year-old lady. Grossly the uterus was enlarged and on sectioning showed multiple tiny abscesses with oozing pus. Endometrium was thick and yellow and microscopy confirmed caseating tuberculosis. The patient was treated with streptomycin and 4-aminosalicylic acid (PAS). She recovered completely after 6 months.[] Although tuberculosis is one of the common infections in the developing countries, there are hardly few reports of tuberculosis involving adenomyotic foci and the uterine myometrium.[]

Tuberculosis of adenomyotic foci are very rare and persistence of infection in these sites can be silent and involve the adjacent myometrium, producing necrotic areas. This silent focus may give rise to a miliary spread. Histopathological examination helps to identify these treatable cases. Source of Support: Nil, Conlict of Interest: None declared.

- 1. De Soldenhoff R. A case of adenomyosis of the uterus with tuberculous infection J Obstet Gynaecol Br Emp. 1948;55:180–3 - 2. Howell HD. A report of three cases of adenomyosis with associated tuberculosis Am J Obstet Gynecol. 1953;66:1337–41 - 3. Mcintosh AD, Richmond H. The association of adenomyosis with tuberculosis; a report of three cases J Obstet Gynaecol Br Emp. 1959;66:115–8 - 4. Rickford B. Adenomyosis of the uterus complicated by tuberculosis Proc R Soc Med. 1955;48:452. - 5. Rangam CM, Gupta JC, Bhagwat AG. Adenomyosis with genital tuberculosis J Indian Med Assoc. 1962;39:262. - 6. Shaikh MA, Sadiq S, Noorani K. Adenomyosis with tuberculosis of uterus J Pak Med Assoc. 2001;51:47–8