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 Table of Contents 
CASE REPORT
Year : 2018  |  Volume : 9  |  Issue : 3  |  Page : 162-164  

Retained fetal bones: An unusual cause of granulomatous reaction on papanicolaou smear


1 Department of Pathology, Hamdard Institute of Medical Sciences and Research, New Delhi, India
2 Department of Obstetrics and Gynaecology, Hamdard Institute of Medical Sciences and Research, New Delhi, India

Date of Web Publication21-Sep-2018

Correspondence Address:
Sujata Jetley
Department of Pathology, Hamdard Institute of Medical Sciences and Research, Jamia Hamdard, New Delhi - 110 062
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmh.JMH_65_18

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   Abstract 


Granulomas are a rare finding on Papanicolaou (Pap) smear which if encountered are usually attributed to tuberculosis, especially in an endemic country like India. Here, we report an interesting case of a 40-year-old female presenting with blood-stained discharge and chronic pelvic pain for 8 years. She was advised Pap smear which showed granulomatous inflammation suggestive of tuberculosis. The patient was worked up for tuberculosis which was noncontributory. Dilatation and curettage was done which revealed multiple small bones and bony chips in the endometrial cavity. Following the removal of bones, the patient showed considerable symptomatic improvement. Repeat Pap smear did not reveal any evidence of granuloma. Even after extensive search of literature, we did not come across any such case report in which intrauterine retention of fetal bones evoked a granulomatous response in cervical smears though the presence of uterine granulomas in response to foreign body has been well documented.

Keywords: Granuloma, Papanicolaou smear, retained fetal bones


How to cite this article:
Khan S, Anwar A, Jetley S. Retained fetal bones: An unusual cause of granulomatous reaction on papanicolaou smear. J Mid-life Health 2018;9:162-4

How to cite this URL:
Khan S, Anwar A, Jetley S. Retained fetal bones: An unusual cause of granulomatous reaction on papanicolaou smear. J Mid-life Health [serial online] 2018 [cited 2018 Dec 11];9:162-4. Available from: http://www.jmidlifehealth.org/text.asp?2018/9/3/162/241944




   Introduction Top


Cervical Papanicolaou (Pap) smear plays an important role in diagnosing tuberculosis by noninvasive technique in which the presence of epithelioid cells and Langhans type of giant cells is considered diagnostic of this disease.[1] However, in the presence of granulomatous inflammation, other causes of granulomatous cervicitis should also be considered and ruled out.[2]

Here, we report a very unusual case of a 40-year-old female who presented with chief complaints of blood-stained vaginal discharge and chronic pelvic pain for 8 years. Pap smear revealed numerous multinucleated giant cells having langhanoid morphology as well as foreign body type along with epithelioid granulomas in an inflammatory background suggestive of tuberculosis. However, on dilatation and curettage (D&C), multiple bony chips were taken out suggestive of retained fetal bones. Following removal of bones, repeat Pap smear was done in 6 weeks, which showed moderate inflammation without any evidence of granuloma.

The possibility of intrauterine retention of fetal bones evoking a granulomatous response on Pap smear has not been previously described, and to the best of our knowledge, this is the first such case being reported in the world literature.


   Case Report Top


A 40-year-old P6L6A1 female presented with complaints of recurrent blood-stained vaginal discharge with chronic pelvic pain for 8 years. However, she had normal menstrual cycle without dysmenorrhea. She also gave a history of abortion 10 years back which occurred at around 12 weeks of pregnancy. General physical examination did not reveal any abnormality. Pelvic examination revealed multiparous uterus with tender adnexa.

She was given a course of antibiotics, following which Pap smear was done. It showed epithelioid granulomas with numerous multinucleated giant cells both of Langhans type and foreign body type [Figure 1] and [Figure 2]. Severe inflammation was seen in the background. Ultrasonography revealed thick linear discontinuous dense echogenic content within the endometrial cavity with dense posterior acoustic shadowing suggestive of calcification [Figure 3]. However, the Mantoux test, erythrocyte sedimentation rate, and chest X-ray were normal.
Figure 1: Smear shows epithelioid granuloma with multinucleated giant cells in an inflammatory background (Pap, ×40)

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Figure 2: Smear shows multinucleated giant cells both of Langhans and foreign body type (Pap, ×40)

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Figure 3: USG shows thick linear discontinuous dense echogenic content within the endometrial cavity with dense posterior acoustic shadowing suggestive of calcification

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The patient was taken up for D&C along with cervical biopsy for tissue diagnosis as well as for excluding tuberculosis. On D&C, there was a gritty feel in the cavity. Several bone pieces were removed, the largest piece measuring >2 cm. Histopathology of endometrial tissue showed inflammatory exudates admixed with epithelioid histiocytes and giant cells around bony spicules [Figure 4]. Cervical biopsy was suggestive of chronic cervicitis. AFB smear and BACTEC culture for tuberculosis from endometrium were sterile.
Figure 4: Section shows inflammatory exudates admixed with epithelioid histiocytes and giant cells around bony spicules (H and E, ×40)

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During follow-up, the patient was planned for hysteroscopy in postmenstrual period to confirm complete removal of bony spicules, since D&C is a blind procedure and hysteroscopy was not done initially due to strong suspicion of tuberculosis. Hysteroscopy showed intrauterine scarring and fibrosis of uterine cavity and no remnant of fetal bones. After removal of the retained bone fragments, the patient showed considerable symptomatic improvement on follow-up and repeat Pap smear after few weeks did not show any granulomas.


   Discussion Top


Cervical Pap smear plays an important role in diagnosing various inflammatory and neoplastic disorders of the cervix. The incidence of tuberculosis has increased recently, and therefore, abnormal Pap smear characterized by the presence of epithelioid cells and Langhans type of giant cells evokes a high index of suspicion of genital tuberculosis, especially in an endemic country like India.[1] However, other causes of granulomatous cervicitis should be considered and ruled out.

The presence of epithelioid cells and multinucleated histiocytic cells on Pap smear is very rare and is characteristically seen in tuberculosis. Similar multinucleated histiocytic giant cells can be seen in other conditions too. In postmenopausal smears and postradiotherapy smears, these multinucleated cells show even distribution of nuclei and a more definite outline, sometimes containing phagocytosed debris with radiation-induced changes.[3] Multinucleated cells of herpesvirus are of epithelial origin having smaller number of nuclei and characteristic crowding/molding without overlapping with eosinophilic inclusion present in nuclei and cytoplasm. Syncytial trophoblastic giant cells are very rarely found in cervical smears. They can be round/irregularly shaped, and nuclei show coarse granular chromatin with pale blue or amphoteric fluffy cytoplasm.[4] In our case, few aggregates of epithelioid cells were seen along with many multinucleated giant cells which were showing both langhanoid morphology and foreign body cell type.

Rare entities that include neoplastic conditions may also give rise to important diagnostic pitfalls which cytologists need to be aware of while reporting Pap smears. For example, cases of granulomatous cervicitis due to tuberculosis have been erroneously diagnosed clinically and cytologically as squamous cell carcinoma.

In our case, the presence of granulomas in Pap smear was also confirmed on histopathology wherein granulomatous reaction was seen around retained fetal bones. Detecting granulomas in the uterus during histopathologic examination usually suggest certain pathologic conditions which include tuberculosis, atypical mycobacteria, endemic mycosis, actinomycosis, and parasites. Noninfectious causes include foreign body reaction, Crohn's disease, sarcoidosis, medications, lymphoma, and other neoplastic conditions.[5] Postsurgical granulomas can also occur presumably representing a reaction to sutures or other foreign materials.[6] In the present case too, the granulomatous response in endometrium was due to the presence of retained fetal bones which acts as a foreign body.

Granulomatous reaction on cytology due to retained fetal bones is a new finding not reported earlier probably because cytology is not described in most of the studies where fetal bones were removed in infertility patients. Removal of fetal bones on D&C with a history of late termination of pregnancy and the absence of systemic granulomatous disease confirmed that granulomatous reaction on Pap smear was primarily due to the presence of retained intrauterine fetal bones.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Seth A, Kudesia M, Gupta K, Pant L, Mathur A. Cytodiagnosis and pitfalls of genital tuberculosis: A report of two cases. J Cytol 2011;28:141-3.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Chowdhury NN. Overview of tuberculosis of the female genital tract. J Indian Med Assoc 1996;94:345-6, 361.  Back to cited text no. 2
    
3.
Kalyani R, Sheela S, Rajini M. Cytological diagnosis of tuberculous cervicitis: A case report with review of literature. J Cytol 2012;29:86-8.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Samantaray S, Parida G, Rout N, Giri SK, Kar R. Cytologic detection of tuberculous cervicitis: A report of 7 cases. Acta Cytol 2009;53:594-6.  Back to cited text no. 4
    
5.
Almoujahed MO, Briski LE, Prysak M, Johnson LB, Khatib R. Uterine granulomas: Clinical and pathologic features. Am J Clin Pathol 2002;117:771-5.  Back to cited text no. 5
    
6.
Bardales RH, Valente PT, Stanley MW. Cytology of suture granulomas in post-hysterectomy vaginal smears. Diagn Cytopathol 1995;13:336-8.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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