Case report

A 52 year old woman was admitted with complaints of increasing headaches and generalised weakness for the past 3 months. There were no other neurological symptoms and she denied any history of fever, cough, diarrhoea, bone pains, vaginal discharge, bleeding, dyspareunia, abdominal discomfort, or weight loss. She was postmenopausal for 2 years with a normal menstrual history previously. There was no history of extramarital sexual contacts or any venereal disease in the patient or her spouse. Examination of cardiovascular, chest, abdomen, and nervous system was unremarkable. Breast examination was normal. Gynaecological examination revealed an abnormal cervix with a small growth and irregularity on its anterior lip with no other abnormal finding. A biopsy from the involved site was taken. Contrast enhanced magnetic resonance imaging (MRI) of the brain revealed multiple ring enhancing lesions in cerebral hemispheres and cerebellum (fig 1). Cerebrospinal fluid (CSF) examination revealed absence of pleocytosis, and normal sugar and protein indices. No organism was identified on staining or culture. Serology for brucellosis, toxoplasmosis, and cysticercosis was negative in both CSF and serum. A Mantoux test was performed but was negative. Ultrasound of the abdomen revealed calcification in the region of the cervix. Chest x ray, computed tomography (CT) of the abdomen, pelvis and chest, colonoscopy, and barium meal follow through study were normal. ELISA for HIV was non-reactive. The cervix biopsy revealed hyperplastic squamous epithelium, epitheloid cell granulomas with central necrosis, and Langhan’s type of giant cells (fig 2). Staining for acid fast bacilli and fungus was negative. Culture of the tissue did not grow any organism. The patient was started on four drug antitubercular therapy (ATT) with oral steroids. Repeat examination of the cervix was normal after 3 months and repeat cranial MRI done at intervals thereafter has shown resolution of lesions.

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Figure 1

Cranial MRI, post-contrast sagittal section showing ring enhancing lesions (arrows) in the cerebral hemispheres and cerebellum.

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Figure 2

Histopathology of the cervix biopsy specimen showing multiple epitheloid cell granulomas (large arrow) with giant cells (small arrow).

Comment

Both central nervous system (CNS) tuberculosis and genital tract tuberculosis are observed in endemically affected populations. Usually, the primary focus is elsewhere, the common being the lung,^1,2 and is silent by the time the disease manifests in the CNS or the genital tract. An accurate estimate of the incidence of genital tuberculosis is difficult because of infected asymptomatic carriers^2,3 with genital tuberculosis being diagnosed more in relation to infertility.^3,4 Postmenopausal genital tuberculosis is uncommon, possibly because of hormone dependence of infection and adequate blood supply at younger ages.^2,4,5 Tubercular cervicitis is rare with an approximate incidence of 2.5–10% of all genital tuberculosis.^3,4 Primary involvement of the cervix is still rarer, and is thought to be either sexually transmitted through a partner with epididymo-orchitis, or through his infected sputum used as a lubricant.³ Tuberculomas are circumscribed focal granulomatous masses of tubercular origin, which may be single or multiple, vary in size, perilesional oedema or meningeal reaction, produce variable clinical features, and are uncommon at extremes of age.^1,6 CSF examination and polymerase chain reaction may be normal in pure parenchymal forms of CNS tuberculosis.¹ Tubercular bacilli may be scant in hypertrophied cervix and lead to a negative acid fast bacilli stain and culture.⁵

In the present case, we were considering both an infective as well as a mitotic pathology. Since women are known to harbour asymptomatic genital tuberculosis, a thorough clinical examination can be helpful in the presence of cranial lesions with a wide differential diagnosis.

Contributors

RB, SP, PS, DS, SG were following this patient clinically; RS provided the pathology details and the image; the manuscript was written by RB and read, edited, and finalised by all authors.