|LETTER TO EDITOR
|Year : 2014 | Volume
| Issue : 3 | Page : 392-393
Detection of a case of cervical dysplasia with co-existent cervical tuberculosis by pap smear examination
Seth Ankit1, Kudesia Madhur1, Gupta Kusum1, Pant Leela2, Mathur Anjali1
1 Department of Pathology, Kasturba Hospital, Daryaganj, Delhi, India
2 Department of Pathology, Hindurao Hospital, MalkaGanj, Delhi, India
|Date of Web Publication||10-Dec-2014|
Dr. Seth Ankit
Department of Pathology, Kasturba Hospital, Daryaganj, Delhi
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Ankit S, Madhur K, Kusum G, Leela P, Anjali M. Detection of a case of cervical dysplasia with co-existent cervical tuberculosis by pap smear examination. Indian J Cancer 2014;51:392-3
|How to cite this URL:|
Ankit S, Madhur K, Kusum G, Leela P, Anjali M. Detection of a case of cervical dysplasia with co-existent cervical tuberculosis by pap smear examination. Indian J Cancer [serial online] 2014 [cited 2019 Sep 15];51:392-3. Available from: http://www.indianjcancer.com/text.asp?2014/51/3/392/146773
A 22-year-old married Indian lady presented with complaints of anterior vaginal ulceration and bloodstained discharge per vaginum. She had no history of anorexia, weight loss, fever, or pulmonary complaints. She denied a history of sexually transmitted disease or promiscuity in self or her husband. There was no past history of tuberculosis in the patient or her family. Per vaginum and per speculum examinations showed thickening of fornices with thickened, unhealthy, and ulcerated cervix, which bled on touch. Erythrocyte sedimentation rate (ESR) was raised to 35 millimeters (mm). Montoux test was positive at 20-mm. Enzyme-linked immunosorbent assay for human immune deficiency virus 1 and 2 were negative. Venereal disease research laboratory test was also negative. Abdominal ultrasound showed presence of loculated fluid. Chest X-ray was unremarkable. Microscopic examination of Pap smear More Detailss showed epithelioid granulomas, occasional macrophages, lymphocytes, Langhans' giant cells, and focal necrotic material. A few clusters of metaplastic and intermediate squamous cells showed koilocytosis, slight increase in nucleo-cytoplasmic ratio, mild chromatin clumping, and nuclear folding [Figure 1]. Pap smears were negative for acid-fast bacilli (AFB). Cytological diagnosis of low-grade squamous intraepithelial lesion with granulomatous cervicitis (possibly tuberculous) was made. Histopathological examinations of cervical and endometrial biopsies were consistent with tuberculous cervicitis (AFB positive) with mild ectocervical dysplasia and morphological changes consistent with human papilloma virus (HPV) infection, along with tuberculous endometritis (AFB positive) [Figure 2]a and b. The patient was given anti-tuberculous therapy for 6 months, to which she responded well. Repeat Pap smears were unremarkable after 2 months.
|Figure 1: Cervical smear showing HPV changes. Few developing granulomas are also seen (arrows). Inset (left) shows epithelioid giant cell. Inset (right) shows well-developed HPV changes in another area (Pap, ×400)|
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|Figure 2: (a) HPV changes in ectocervical epithelium (H and E, ×100), (b) tuberculous cervicitis (H and E, ×100)|
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Distinction between cervical malignancy and tuberculosis is at times challenging for clinicians because of similar symptoms as well as gynecologic and colposcopic examination findings.  Cytological diagnosis of cervical neoplasia can be suspected by demonstration of features of dysplasia or malignancy in at least few clusters, evidence of HPV infection, single cells in the background with dysplastic or malignant features, and tumor diathesis, while presence of typical epithelioid granulomas with the presence of Langhans' giant cells are sufficient for diagnosis of cervical tuberculosis, particularly if other causes of granulomatous cervicitis are excluded. However, at times, it is difficult to differentiate the two because cervical tuberculosis may also result in marked reactive changes, bordering dysplasic changes in the Pap smears, characterized by presence of ragged sheets of reactive epithelial cells having enlarged nuclei and prominent nucleoli, with non-specific inflammation in the background. Epithelioid cells with large nuclei may also be reported as atypical cells.  On the other hand, giant cells and granulomas may appear in the surrounding stroma of the tumor as a result of foreign body reaction,  consequent to the reaction to keratin. In such a scenario, diagnosis of cervical tuberculosis or a co-existent disease can be made by searching for epithelioid and Langhans' cells, followed by cervical biopsy, AFB staining, and culture methods.
While association of some of the cases of cervical neoplasia concomitant with cervical tuberculosis may be incidental, it is important to consider if a pre-existing cervical malignancy could be responsible for the development of superimposed tubercular lesion in cervix. A diminished immunity due to local or systemic effects of tumor may lead to reactivation of dormant tuberculosis.  Radiation or chemotherapeutic agents administered to cure or prevent relapse of malignancy may also exacerbate pre-existing tuberculous lesion. 
In our opinion, despite the rare incidence, tuberculosis of the cervix should be looked for while evaluating a case for cervical carcinoma and vice versa because of possibility of high morbidity and mortality in patients with co-existent disease. A simple Pap smear examination can be a stepping-stone to achieve it.
| » References|| |
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Misch KA, Smithies A, Twomey D, O'Sullivan JC, Onuigbo W. Tuberculosis of the cervix: Cytology as an aid to diagnosis. J Clin Pathol 1976;29:313-6.
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[Figure 1], [Figure 2]
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