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Images in Gynecologic Surgery Surface Architecture in Endometrial Tuberculosis Atul Kumar, MS*, and Alka Kumar, MS From the Hysteroscopic Surgery Division, Women’s Health Centre, Jaipur, India (both authors). DISCUSS You can discuss this article with its authors and with other AAGL members at http://www.AAGL.org/jmig-21-4-JMIG-D-14-00035 Use your Smartphone to scan this QR code and connect to the discussion forum for this article now* * Download a free QR Code scanner by searching for ‘‘QR scanner’’ in your smartphone’s app store or app marketplace. Endometrial tuberculosis is a frequent cause of infer- tility, and its detection is often difficult. A 29-year-old woman with a 5-year history of primary infertility and scanty periods was referred for hysteroscopic evaluation. The endometrial thickness was 7 mm at vaginal ultrasound. Panoramic hysteroscopy with 1! magnification using a conventional telescope (27005 BA; Karl Storz GmbH & Co., Tuttlingen, Germany) [1] revealed an endometrium un- remarkable except for subtle scarring, which could also be overlooked (Fig. 1). The endometrium was next visualized using a Hamou Micro-Hysteroscope II (26157 BT; Karl Storz) [1–5] in the panoramic view at 20! at-source magnification, which revealed a rough-looking endome- trium as though it had been sprinkled with a coarse whitish powder (Fig. 2, A and B). The endometrial surface was bumpy, with diffusely scattered small conical papillary pro- jections, and no endometrial glands were observed (Fig. 2, A and B). The apex of a papillary projection located in the center of the frame (Fig. 2B) seemed to have been nibbled by a mouse, and the nibbled circular rim was impregnated with white caseous-like micro deposits. Visu- alization in the contact mode using 80! at-source magnifi- cation further revealed those micro deposits, which were missed during the 20! panoramic visualization (Fig. 3). A targeted biopsy specimen was obtained from the region of the diseased endometrium, and the diagnosis of tubercu- losis was established via polymerase chain reaction [3,4,6]. Histopathology revealed an endometrium with epitheloid granulomas. Usually granulomas take up to 2 weeks to develop over the pars functionalis, which is shed every 4 weeks [7], and this could be why the tubercular micro deposits were not able to fully develop over the endometrial surface to a size sufficient to be visible at 1! magnification and why the deposits were observed only at 20! at-source magnifi- cation (Fig. 2, A and B). We have observed such images in other cases of endometrial tuberculosis, and such appear- ance is pathognomonic of the disease. In the present study the magnified peculiar bumpy endometrial surface architec- ture observed in the panoramic mode by placing the Fig. 1 Visualization under 1! magnification reveals an almost unremarkable endometrium. The authors declare no conflicts of interest. Corresponding author: Atul Kumar, MS, Hysteroscopic Surgery Division, Women’s Health Centre, 11 Rathore Nagar, Queens Rd, Viashali Nagar, Jai- pur 302021, India. E-mail: [email protected] Submitted January 21, 2014. Accepted for publication January 21, 2014. Available at www.sciencedirect.com and www.jmig.org 1553-4650/$ - see front matter Ó 2014 AAGL. All rights reserved. http://dx.doi.org/10.1016/j.jmig.2014.01.020
