A 37-year-old lady (para 2 living 2) reported to have last normal menses period 2 years ago. Presented with per vaginal discharge for 2 years which was copious, yellowish, and non-itchy, which made her use one pad each day. She reports to have an intra-uterine device inserted 2 years ago which was later removed. She denies any history of lower abdominal pain, postcoital bleeding or cough, fever, loss of weight and night sweats. During her illness, she has been treated with variety of antibiotics and antifungal medications without improvement. She was otherwise well and with no significant medical history. She has no known drug or food allergy. There is no any family history of gynecological or other malignancies that was reported. She has delivered two times through cesarean section, and there is no history of other gynecological procedures reported. She is non-smoker and does not consume any alcohol. During childhood, she received Bacillus Calmette-Guerin (BCG) vaccination.
On examination, she was alert, not pale, no lower limb edema, and had stable vital signs. The abdominal examination revealed normal contour, a pfannenstiel scar, soft and non-tender. There was no mass palpable, and uterus was not bulky. The rest of the systemic examination was normal.
Speculum examination was unremarkable except with blood oozing from the cervix. Bimanual examination was unremarkable, endocervical swab was done which was negative on gram stain and no organism growth on culture media.
Pap smear was not performed due to vaginal bleeding; however, a pap smear done 1 year ago revealed inflammatory cells.
Transvaginal ultrasound was performed which showed an anteverted uterus with a grossly abnormal endometrial echo pattern. The endometrium was heterogenous and had an irregular surface (Figure 1).
After the history and physical examination, we had a differential diagnosis of endometritis; the patient was then scheduled for diagnostic hysteroscopy. Preoperative investigations included a hemoglobin level of 11.4 g/dL, white blood cell 5.61/L, platelets 181/L, and CA-125 (Serum) 41.78 U/mL (0-35). The patient's hepatitis and HIV status were negative. A chest X-ray showed no evidence of pulmonary TB.
Intra-operative findings revealed a stenosed cervical canal and uterine synechiae was present. Release of uterine synechiae and endometrial biopsy via curetting was done. Blood loss was not excessive and the patient was discharged home the same day. Histopathology of the curettings showed numerous caseating and non-caseating granulomas with plasma cells, Ziehl-Neelsen stain for acid fast bacilli was positive (Figure 2).
Based on the history and results of endometrial biopsy, our provisional diagnosis was endometrial TB. The department of internal medicine was consulted and initiated the patient on one combined tab daily, consisting isoniazid, rifampicin, ethambutol, and pyrazinamide for 2 months (Intensive phase), then tab (isoniazid, rifampicin) for 4 months (Continuation phase).
Upon follow-up, she reports bleeding to have ended in the fourth week of her treatment. She has been doing well and disease-free after completion of the treatment.