The case covers one of the unique gynecological problems that may affect women. In the case, the patient is unable to conceive because the uterus cannot support the implantation of the fertilized egg. Many trials and tests were conducted in determining the root cause of the problem. The different test reveals that the patient had no major medical problem. Following many diagnostic tests, Dr. Richard S. Lego, in collaboration with the pathologists opted for differential diagnosis. The doctors conducted histopathology of non-caseating granulomas and this help give some of the possible causes of the problem (Legro, Hurtado, Kilcoyne, and Roberts, 2016). The doctors also requested the patient to undergo repeat endometrial biopsy for mycobacterial and fungal cultures. They also tested the integrity of the menstrual blood. Based on these, the T-SPOT test and tuberculin skin test were both positive, and both mycobacterial cultures grew drug-susceptible M. tuberculosis. It was realized that cultures of both the menstrual blood and the endometrial-biopsy specimen were positive for M. tuberculosis complex, which is broadly susceptible to multiple antibiotic agents. The final pathological diagnosis was tuberculous endometritis. The patient, based on these test, was suffering from genitourinary tuberculosis.
The doctors had to initiate a viable management plan. The first management focused on prompt initiation of combination antitubercular therapy (Legro, Hurtado, Kilcoyne, and Roberts, 2016). A standard four-drug regimen with isoniazid (and pyridoxine supplementation), rifampin, ethambutol, and pyrazinamide were administered to the patient. The endometrial scarring was reassessed after completion of treatment. Dr. Jennifer Reedy reveals that culture and staining for menstrual blood were conducted after three months following the treatment and that the results were negative for M. tuberculosis. The doctors continued with the treatment for the other three months before increasing the dose of isoniazid.
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After 12 months, the doctors induced ovulation using gonadotropins and initiated in vitro fertilization. They then transfer a high-quality blastocysts. The patient became pregnant but experienced severe vaginal bleeding after 6 weeks. A test was done and the endometrium showed necrotic immature chorionic villi with no granulomas. Ten months later, the doctors conducted another transfer of blastocysts but ensured that the endometrium was checked. This resulted in successful pregnancy. Although the patient experienced preeclampsia, she delivered a female baby.
Reference
Legro, R.S., Hurtado, R.M., Kilcoyne, A., and Roberts, D. J. (2016). Case 28-2016: A 31-Year- Old Woman with Infertility. N Engl J Med 2016; 375:1069-77. DOI: 10.1056/NEJMcpc1609110
