uterine granuloma is a rare entity and may be either focal or diffuse in nature .
diffuse granulomas represent a local reaction without an obvious cause or may be associated with infection or systemic granulomatous disorders .
infective conditions associated with uterine granulomas could be tuberculosis , atypical mycobacteria , endemic mycosis , cytomegalovirus infection and parasites .
we report two cases of uterine granuloma , the first in which there was diffuse non - necrotizing granuloma .
the second case showed diffuse granulomas with caseation in the myometrium and was positive for acid fast bacillus ( afb ) stain .
a 50-year - old patient presented in august 2010 with heavy and irregular bleeding per vaginum for last 10 months .
she had undergone dilatation and curettage ( d and c ) and cervical biopsy in december 2009 for menorrhagia .
she had a second episode of menometrorrhagia in march 2010 followed by a repeat d and c. the endometrial curettings was reported as simple hyperplasia without atypia .
her general , local examination and routine investigations were normal . a total abdominal hysterectomy with bilateral salpingo - oophorectomy was performed and the patient was discharged in satisfactory condition on eighth post - operative day .
histology revealed endometrium in proliferative phase and myometrium showed multiple non - necrotizing epithelioid cell granulomas .
photomicrograph showing non - caseating epithelioid cell granulomas with multinucleated giant cells present in the myometrium ( h and e , 200 ) a 40-year - old presented with pain and mass lower abdomen of five months duration with no menstrual irregularity .
general physical examination was normal , local examination was suggestive of fibroid corresponding to size of 18 weeks pregnant uterus .
ultrasonography revealed a large single intramural fibroid 10  9.7 cm with thin endometrium and normal ovaries .
histopathological examination revealed endometrium in secretory phase , uterine tumor as leiomyoma and in addition myometrium showed caseating epithelioid granulomas along with langerhans and foreign body giant cells [ figure 2 ] . stain for afb was positive .
patient was started on att despite hysterectomy and absence of tuberculosis elsewhere because the adnexa was left behind where the possibility of a tubercular focus could not be ruled out .
a 50-year - old patient presented in august 2010 with heavy and irregular bleeding per vaginum for last 10 months .
she had undergone dilatation and curettage ( d and c ) and cervical biopsy in december 2009 for menorrhagia .
she had a second episode of menometrorrhagia in march 2010 followed by a repeat d and c. the endometrial curettings was reported as simple hyperplasia without atypia .
her general , local examination and routine investigations were normal . a total abdominal hysterectomy with bilateral salpingo - oophorectomy was performed and the patient was discharged in satisfactory condition on eighth post - operative day .
histology revealed endometrium in proliferative phase and myometrium showed multiple non - necrotizing epithelioid cell granulomas .
photomicrograph showing non - caseating epithelioid cell granulomas with multinucleated giant cells present in the myometrium ( h and e , 200 )
a 40-year - old presented with pain and mass lower abdomen of five months duration with no menstrual irregularity .
general physical examination was normal , local examination was suggestive of fibroid corresponding to size of 18 weeks pregnant uterus .
ultrasonography revealed a large single intramural fibroid 10  9.7 cm with thin endometrium and normal ovaries .
histopathological examination revealed endometrium in secretory phase , uterine tumor as leiomyoma and in addition myometrium showed caseating epithelioid granulomas along with langerhans and foreign body giant cells [ figure 2 ] . stain for afb was positive .
patient was started on att despite hysterectomy and absence of tuberculosis elsewhere because the adnexa was left behind where the possibility of a tubercular focus could not be ruled out .
when clinicians encounter patients with granulomatous inflammation , they are faced with a diagnostic dilemma to determine its cause .
non infections conditions include granulomatous inflammation following surgical instrumentation , foreign body reaction , systemic granulomatous disorders like sarcoidosis , systemic vasculitides like giant cell arteritis or may be idiopathic i.e. , without an obvious underlying cause . the first case in our study showed diffuse granulomatous lesions in myometrium of non - necrotizing variety .
there was history of surgical intervention for uterine bleeding in the form of dilatation and curettage done twice at an interval of three months .
, showed that 8 of 11 patients with incidental granulomas of the uterus had a known history of instrumentation , which consisted of dilatation and curettage ( n = 4 ) , endometrial biopsy ( n = 2 ) , hysterosalpingogram ( n = 1 ) and hysteroscopy ( n = 1 ) .
none of the patients had clinical evidence of sarcoidosis or systemic infection and stains for microorganisms were negative .
the clinical scenario of the first case correlates with this study where well formed , non - necrotizing granulomas of the uterus were found with a history of instrumentation .
the patient had endometrial defects as shown on histopathology which can explain all the clinical features .
similarly there was no evidence of systemic granulomatous disease or tuberculosis based on clinical and laboratory evidence .
hence a history of instrumentation may explain the presence of uterine granulomas in the first case . despite its contiguity with endometrium ,
sinha et al . , reported a case of myometrial tuberculosis detected on sonography as multiple anechoic areas of variable size with well defined borders scattered throughout the myometrium .
after receiving antitubercular treatment patient was relieved of menorrhagia and a repeat sonogram showed a homogenous myometrium with absence of anechoic areas .
the second case presented with a pelvic mass suggestive of leiomyoma , confirmed on fnac and had no menstrual complaint .
there was incidental detection of tubercular granulomatous inflammation of myometrium along with leiomyoma in this case .
, in a 31 year study on pathology of female genital tuberculosis reported that microscopic involvement of myometrium was observed in 20% of the cases . in the indian context , tuberculosis remains the most common cause of diffuse granulomas since two thirds of tuberculosis cases in south east asia are found here .
, reviewed 5,085 biopsy specimens ( 3,510 endometrial and 1,575 cervical ) of these 28 endometrial and 2 cervical biopsy specimens were reported as granulomatous inflammation , consistent with tuberculosis .
myometrial involvement was not observed in any of the endometrial biopsy specimens in which myometrium was included .
this supports the infrequent involvement of myometrium in genital tuberculosis . to conclude , uterine granuloma involving myometrium is rare .
there is need for awareness about instrumentation causing granuloma formation , and also to look for an additional pathology such as tubercular granuloma which may present as an incidental finding warranting therapy .
 uterine granulomas confined to the myometrium are uncommon . 
 granulomas maybe infectious , non - infectious or idiopathic in origin . 
 they may be diffuse or focal in nature . in this report 
 , we describe two cases of granulomas of diffuse variety involving the myometrium . 
 the first case shows non - necrotizing granuloma probably related to previous instrumentation . 
 the second case depicts caseating granulomas along with leiomyoma of uterus . 
INTRODUCTION
CASE REPORTS
Case 1
Case 2
DISCUSSION