A 54-year-old nulliparous postmenopausal Indian woman presented to the gynecologic outpatient department of a tertiary referral center, being referred from a primary health clinic, with a complaint of discharge per vaginum for 2 months. It was serous in nature, non-foul smelling, and not associated with pruritus. It was not associated with bleeding or postcoital spotting. She was a known hypertensive on regular treatment, on oral amlodipine and clonidine, for 7 years. There was no history of loss of appetite; however, there was a history of weight loss. The patient did not have any other constitutional symptoms like cough or fever.
The vitals were within normal limits. On per vaginum examination, the perineum appeared unremarkable. Palpation revealed no cystocoele or prolapse of the uterus. Per speculum examination (using a Graves speculum) showed a normal vagina with an ulcerated growth over the anterior lip of the cervix, obliterating the external os. A Papanicolaou smear was then taken using an Ayres spatula. On palpation, the same growth was felt, which bled on touch. However, a bimanual examination revealed a normal-sized uterus, and the fornices were free. The parametria also appeared free. A clinical diagnosis of carcinoma of cervix was made, considering the age. A pap smear taken was sent to the pathology laboratory attached to the tertiary referral center. Subsequently, a cervical biopsy was also done to rule out malignancy. On microscopy, the vaginal smear studied was partly air-dried and showed superficial, intermediate, and parabasal cells along with a few epithelioid cell clusters, numerous Langhans giant cells (Figures 1, 2), lymphocytes, plasma cells, and histiocytes against a background of focal patchy necrosis. A diagnosis of granulomatous cervicitis, probably TB was made and a biopsy requested for confirmation. The histological examination of the cervical biopsy showed tissue bits with ulcerated mucosa overlying tuberculous granulation tissue, which was composed of well-formed granulomas with epithelioid histiocytes, Langhans, and foreign body giant cells with focal necrosis. A modified Gabbett staining for acid fast bacilli showed numerous tubercle bacilli, especially within the giant cells (Figure 3).
The chest x-ray showed fibrous areas, suggestive of old healed TB. The patient was subsequently given antituberculous treatment for 6 months (ethambutol 1 g; isoniazid 300 mg; pyrazinamide 1.5 g; and rifampicin 600 mg for 2 months and isoniazid 300 mg and rifampicin 600 mg for 4 months) following which she was asymptomatic. The follow-up pelvic examination showed a normal cervix on per speculum examination, and the ultrasound scan also showed a uterus of normal size with an endometrium of 1.5 mm thickness. However, 2 months after completing the treatment, she developed cough and breathlessness. The chest x-ray showed a minimal right-sided pleural effusion with underlying opacity, suggestive of an old healed TB or an active lesion. This was followed by a CT, which revealed a mass/consolidation in the right lower lobe. CT-guided fine-needle aspiration cytology from the lesion was planned to differentiate an active pulmonary TB from malignancy, but the patient went against medical advice and did not return for the follow-up.