At the time of pregnancy, she was 38 years old. At 10 weeks gestation, a normal ultrasound was performed without any anomalies. However, at 18 weeks gestation, the patient experienced vaginal bleeding, and an extensive ultrasound revealed a sub-placental hematoma. The fetus did not have any structural abnormalities, and the cervical length was 27 mm. Cervical swabs for gonorrhea, chlamydia, bacterial vaginosis, and yeast infections, as well as a PAP smear showed no anomalies. Unfortunately, she returned to the hospital after a new episode of bleeding and cramps and delivered immaturely at 22 weeks gestation.
The delivery was complicated by a retained placenta, which was evacuated via vacuum curettage. Afterwards, the placenta was sent to the pathologist for further examination. The pathology report showed a necrotic granulomatous inflammation among others (Fig. 1).
During a routine postpartum check-up, the patient reported continuous irregular blood loss and lower abdominal pain. The ultrasound showed an intrauterine homogeneous structure of 13 mm, suspicious for a retained placental tissue. We scheduled her for a hysteroscopy to remove the suspected placental rest.
During this procedure, a large amount of thick, yellow, fibrotic tissue was visualized, which could only be partially resected. The procedure was ended due to reaching maximum fluid loss. The pathology report revealed the same granulomatous inflammation, without signs of placental tissue. After consultation with the pathologist, microbiologist, and internal medicine-interstitial lung disease specialist, the following differential diagnosis was drawn up; TB, actinomyces species, auto-immune vasculitis, and auto-immune diseases. A diagnostic work-up was planned accordingly. More tissue was collected by endometrium aspiration technique, which was send for pathology and culture purposes to examine for actinomyces and TB. The Ziehl-Neelsen (ZN) and auramine testing results were negative.
In addition, blood was taken for IGRA (QuantiFERON-TB) and a wider panel of tests on IL2-R, ANCAs, ENA, and antibodies.
A recent X-ray of the lungs taken because of shortness of breath by the general practitioner showed no signs of lung diseases. The QFT-TB was positive and culture results of the extracted tissue came back positive for Mycobacterium tuberculosis and rifampicin resistant.
Accordingly, the patient was referred to an internal medicine infectious disease specialist for further diagnosis, treatment, and follow-up. An extended history was taken with the patient, but she could not recall any periods of coughing, shortness of breath, or night sweats. A CT scan was performed, which showed a suspected tuberculosis granuloma in the left kidney, this was confirmed by a PET-CT and a biopsy. No other sources containing TB were found.
The Mycobacterium tuberculosis turned out to be isoniazid and rifampicin resistant. Therefore, we referred the patient to University Medical Center Groningen (UMCG), one of the two tertiary specialized centers in the Netherlands. She was discharged after she started with her treatment for multi-drug resistant tuberculosis for a total duration of 15 months, which is partly teratogenic. For this reason, she had to postpone her pregnancy wish. The patient conceived again in 2023, but unfortunately, this pregnancy resulted in a miscarriage at eight weeks gestation.
This case report shows the difficulty of diagnosing extrapulmonary TB in a woman without history of and/or symptoms of tuberculosis in a western country where TB is uncommon.