This patient is a 34-year-old non-obese Ethiopian P0 who presented for care after prolonged (5-6 years) secondary amenorrhea and infertility. She had no past medical history. Past surgical history significant for a myomectomy with Pfannenstiel incision in 2009 in Ethiopia for subserosal fibroids. She immigrated to the United States in 2010. In terms of family history, the patient's older sister had positive TB 20 years ago, for which her sister was treated. No one else in the family was treated for TB. A work up was completed for secondary amenorrhea. At this time there was no evidence of adhesions. A hormonal evaluation was obtained and she was worked up for amenorrhea as well as routine infertility labs, including TSH, prolactin, FSH, LH, AMH and estradiol to assess the entire axis. There was a low ovarian reserve based on AMH (0.61), however the normal values of FSH, LH, estradiol and progesterone levels suggested recent ovulation therefore leaning to more of a uterine pathology. On ultrasonography, the uterus measured 7.5 x 3.5 x 6.2 cm with an unremarkable myometrium. The endometrial stripe measured 4 mm and was noted to be uniform. A hysterosalpingogram performed at age 29 demonstrated no opacification of the left fallopian tube and no intraperitoneal free spill from the right fallopian tube, suggesting occlusion. In November of 2017, the patient underwent a diagnostic hysteroscopy, with findings of mottled endometrium particularly near the right ostia across the fundus. (See Fig. 1). Endometrial curretings from this procedure were collected and sent for TB testing. The pathology from this demonstrated necrotizing granulomas with acid-fast bacilli positive and culture positive for Mycobacterium tuberculosis. A chest x-ray was performed but was negative for any radiographic evidence of active pulmonary TB.
At this time, the patient was started on 2-month course of 4-drug Rifampin, Isoniazid, Pyrazinamide, and Ethambutol (RIPE) therapy followed by 4 months of rifampin and isoniazid. After 6 total months of treatment, the patient returned for a repeat endometrial biopsy. Results from this biopsy demonstrated positive acid-fast bacilli on Kinyoun stain but the cultures did not grow. Per an Infectious Disease consult, the patient was continued on rifampin and isoniazid for an additional 3 months. A second endometrial biopsy was performed in September 2018, which returned culture negative and acid-fast bacilli negative. The patient is currently undergoing treatment an estrogen-priming protocol to attempt to regrow endometrium, and at this point she has begun to have slow return of cyclic spotting after 2 cycles. It remains to be seen if this patient will have potential for future fertility.