Cervical TB kills more but is rarely diagnosed- experts

As Kenya joins the globe in creating awareness on cancer of the cervix this month, experts want emphasis put on cervical tuberculosis.

Kenyan researchers say cervical TB should be considered a differential diagnosis for cervical masses. Currently, the majority of patients in the country with cervix TB are treated as cancer of the cervix.

In a study published in the Journal of Obstetrics and Gynecology of East Africa, cervix TB is associated with high level of morbidity and mortality.

“Cervical cancer and tuberculosis remain significant health concerns,” states a section of the study published on December 12.

Cervical cancer is the second most common cancer among women in Kenya. Out of 5,236 women diagnosed with cervical cancer, at least 3, 211 women die from the disease every year.

TB of the cervix accounts for 0.1 to 0.65 per cent of all tuberculosis cases.

According to the study, genital TB is documented to commonly affect the upper genital tract.

“Approximately five per cent of upper genital tract TB cases are cervical TB,” reads a section of the study.

The study was done by a team of researchers drawn from the Department of Obstetrics and Gynecology and the Department of Human Pathology at the University of Nairobi.  

The researchers reveal that patients having cervical TB, are reported to develop cervical lesions that appear as papillary or vegetative growth; exophytic or ulcerative lesions in the cervix.

“Tuberculosis may spread to the cervix hematogenously, lymphatically, or direct extension,” adds the study.

Findings on the study were based on a 37-year-old nulliparous woman who presented to a gynaecological clinic at Kenyatta National Hospital (KNH), having been referred with post-coital bleeding for examination-under-anaesthesia.

The patient had a five-year history of per vaginal bleeding, a condition that was on and off.

She also had inter-menstrual bleeding that was associated with per vaginal discharge and dyspareunia and post-coital bleeding.

However, she had no history of cervical cancer screening, nor had she been in contact with a TB patient.

At the facility, she underwent speculum examination that revealed a friable cervical mass, and cervical cancer was suspected - she was referred to a gynaecological oncology clinic.

Doctors performed a biopsy of the cervical mass, and made a diagnosis of a cervical mass and pelvic inflammatory disease. She was scheduled for examination under anaesthesia, which revealed normal external genital with normal vaginal walls.

But mass was seen on the cervix involving the entire transformation zone, with a mobile cervix.

“The mass was friable and bled on touch. The mass did not involve the vaginal walls and parametria. The adnexa was free. The uterus was not bulky. The recto-vaginal mucosa was free. An impression of cancer of the cervix stage 1B2 was made,” noted doctors during the study.

Further biopsies were taken for histological examination that demonstrated a heavily inflamed endocervical tissue. The examination within the stroma were necrotizing granulomatous inflammations with attendant giant cells of the Langerhans type.

Doctors noted that features presented during examination were consistent with cervical tuberculosis.

After diagnosis, the patient was managed with anti-tuberculous drugs- rifampicin, isoniazid, ethambutol, and pyrazinamide for six months.

One month after being put on treatment, a vaginal examination showed that the cervical mass had petered out.

The patient did not have cervical mass, even with subsequent follow-up.

In the study, researchers noted that the upper genital tract organs most affected by tuberculosis are the fallopian tubes at between 95 and 100 per cent.

Per percentage of endometrium was ranged 50 to 60, while the ovaries were at 20 to 30 per cent and 0.1 to 0.65 per cent of TB cases.

“Genital tract tuberculosis may present with abdominal pain, constitutional symptoms, menstrual irregularities, and vaginal bleeding. It may mimic malignancies. Making a diagnosis of cervical tuberculosis may be difficult due to its atypical clinical presentation,’ said researchers.

Cervical TB may be introduced to a woman by a partner with tuberculous epididymitis or disease in the genitourinary areas.

In addition, it was revealed that cervical TB as a primary infection is rare, but sputum is thought to be a transmission route, if used as a sexual lubricant.

It was explained that hematogenous spread typically affecting the pelvic organs, with the chest as a primary focus has been implicated, while spread to the cervix may be from a lymphatic or direct extension.

The primary lesion may have healed upon presentation.

“Given that 80 per cent of cases occur in the reproductive period, hormone dependence of the infection has been hypothesized,”

In a macroscopical examination, TB of the cervix appears as friable papillary or vegetative masses or hypertrophy of the cervix, which may simulate invasive cervical cancer.

Pap smears, which is gradually adopted by Kenyan women, may provide a tentative diagnosis as granulomas from endometrial lesions may appear in Pap smears.

“A suspicion for tuberculous endometritis should be raised if epithelioid cells are present in smears.