Tuberculosis Endometrial Polyp
结核 子宫内膜息肉

Abstract 抽象的

1. Introduction 一、简介

Endometrial polyps are very common and are often discovered during the exploration of infertility. Most polyps are mucosal benign tumors. Genital tuberculosis is a frequent disease in nondeveloped countries but very rare in developed countries. It can be an etiology for infertility.
子宫内膜息肉很常见，经常在探查不孕不育的过程中被发现。大多数息肉是粘膜良性肿瘤。生殖器结核是非发达国家的常见疾病，但在发达国家却非常罕见。它可能是不孕不育的病因。

2. Case Presentation 2. 案例展示

A 31-year-old woman (origin: Algeria) was referred to our academic gynecological institute for unexplained primary infertility. The patient presented with no complaint. Hysteroscopy showed a 10 mm sized endometrial polyp located on the left lateral wall of the uterine isthmus. Neither adhesion (synechia) nor other abnormality was noted during hysteroscopy. Hysteroscopic view of superficial blood vessels showed regular vascular pattern, with a classic benign appearance. No other infertility etiology was discovered. The polyp was removed using hysteroscopic bipolar loop (24 French). Pathology (Figure 1) showed lymphocytic and plasmacytic chronic inflammatory modification, granulomatous modification, and gigantocellular modification, which lead to the diagnosis of tuberculosis. No acid fast organism was seen on Ziehl-Neelsen staining. A chest thorax X-ray revealed no sign of pulmonary tuberculosis. The patient underwent antituberculosis therapy (rifampicin, isoniazid, pyrazinamide, and ethambutol) during one year. Posttreatment hysteroscopy revealed no abnormality. Followup of the patient was 18 months. She did not start trying to get pregnant since the treatment (marital problems).
一名 31 岁女性（原籍：阿尔及利亚）因不明原因原发性不孕症被转诊至我们的妇科研究所。患者没有任何主诉。宫腔镜检查显示，子宫峡部左侧壁有一个 10 毫米大小的子宫内膜息肉。宫腔镜检查期间未发现粘连（粘连）或其他异常。宫腔镜观察浅表血管显示规则的血管模式，具有典型的良性外观。没有发现其他不孕病因。使用宫腔镜双极环（24 French）切除息肉。病理学（图1）显示淋巴细胞和浆细胞慢性炎症改变、肉芽肿改变和巨细胞改变，这导致了结核病的诊断。 Ziehl-Neelsen 染色未发现抗酸微生物。胸部X光检查未发现肺结核迹象。患者在一年内接受了抗结核治疗（利福平、异烟肼、吡嗪酰胺和乙胺丁醇）。治疗后宫腔镜检查未见异常。患者的随访时间为 18 个月。治疗后她没有开始尝试怀孕（婚姻问题）。

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Figure 1  图1

Pathological examination of the endometrial polyp. Microscopic analysis of the surgically removed endometrial polyp showed superficial erosive inflammation with numerous nonnecrotizing granulomas containing Langhans giant cells. No acid fast organism was seen on Ziehl-Neelsen staining.
子宫内膜息肉的病理检查。对手术切除的子宫内膜息肉的显微镜分析显示，表面有糜烂性炎症，伴有大量含有郎罕斯巨细胞的非坏死性肉芽肿。 Ziehl-Neelsen 染色未发现抗酸微生物。

3. Discussion 三、讨论

This is the first reported case of endometrial tuberculosis diagnosed following the removal of a polyp with classical benign appearance.
这是第一例在切除具有典型良性外观的息肉后诊断出的子宫内膜结核病例。

Due to the paucibacillary nature of endometrial tuberculosis, conventional methods of diagnosis (histopathological examination and conventional mycobacterial culture) have low sensitivity (low detection rate). In several studies, PCR was found to be useful in the diagnosis of endometrial tuberculosis when clinically suspected; however, false negative PCR may be observed. In the current case, pathology showed lymphocytic and plasmacytic chronic inflammatory modification, granulomatous modification, and gigantocellular modification, which lead to the diagnosis of tuberculosis.
由于子宫内膜结核缺乏杆菌性质，常规诊断方法（组织病理学检查和常规分枝杆菌培养）敏感性较低（检出率低）。多项研究发现，当临床怀疑有子宫内膜结核时，PCR 有助于诊断。然而，可能会观察到假阴性 PCR。在本例中，病理显示淋巴细胞和浆细胞慢性炎症改变、肉芽肿改变和巨细胞改变，从而诊断为结核病。

The case is most likely tuberculosis, although no acid fast organisms were seen on Ziehl-Neelsen staining. The presence of Langerhans giant cells is not specific for tuberculosis or even for mycobacterial disease, and that they are found in nearly every form of granulomatous disease, regardless of etiology. The differential diagnosis of tuberculosis endometrial polyp on pathological findings is other infectious (Mycobacterium leprae and histoplasmosis) or noninfectious diseases (beryllium disease, cancer, and sarcoidosis). Genital tuberculosis is usually associated with a high rate of intrauterine adhesions [1–4]. The influence of tuberculosis endometritis or endometrial polyp on fertility is doubtful. However, a hypothesis is that, during the process of infection or reactivation, the tuberculosis bacilli may induce immune modulation within the local tissues (endometrium). There is a release of harmful cytokines (IL2, TNFα, and INFγ). The immunomodulatory impact will affect adversely the endometrial receptivity.
尽管齐尔-尼尔森染色没有发现抗酸微生物，但该病例很可能是结核病。朗格汉斯巨细胞的存在并不是结核病甚至分枝杆菌疾病所特有的，而且它们几乎存在于所有形式的肉芽肿性疾病中，无论病因如何。结核性子宫内膜息肉根据病理结果与其他感染性疾病（麻风分枝杆菌和组织胞浆菌病）或非感染性疾病（铍病、癌症和结节病）鉴别诊断。生殖器结核通常与宫腔粘连的高发生率相关[1-4]。结核性子宫内膜炎或子宫内膜息肉对生育的影响值得怀疑。然而，一种假设是，在感染或重新激活的过程中，结核杆菌可能会诱导局部组织（子宫内膜）内的免疫调节。有害细胞因子（IL2、TNFα 和 INFγ）会释放。免疫调节作用将对子宫内膜容受性产生不利影响。

References 参考