Int J Gynecol Obstet, 1992, 31: 293-296 International Federation of Gynecology
293 and Obstetrics
Proximal tubal obstruction schistosomiasis G.S. Letteriea
associated with tubal
and L. Sakasb
“Reproductive Endocrinology Service, Department of Obstetrics and Gynecology and ‘Anatomic Pathology Service, Department oJ’Pathology. Tripler Army Medical Center, Honolulu, Hawaii 96859-5060 (USA) (Received
May 28th.
(Accepted
July 30th, 1991)
1991)
Abstract The gynecologic consequences of schistosomiasis may range from minimal injlammation of tubal serosa to more intense reactions involving the periadnexal regions. Complete obliteration of the tubal lumen has not been described. We describe a case of proximal tubal obstruction associated with tubal schistosomiasis. Keywords:
Proximal Schistosomiasis.
tubal
obstruction;
Case report
Introduction
Schistosomiasis is a disease affecting a variety of organ systems with a wide spectrum of clinical consequences. Sites of pelvic infection include cervix, ovary, vagina and uncommonly, the fallopian tube [4]. In endemic areas, it has been associated with infertility in approximately 60% of the population [l]. Tubal schistosomiasis has been previously implicated in the etiology of ectopic pregnancy, salpingitis and infertility [2,5,8]. Detailed analysis of the sequelae of tubal schistosomal infestation suggest that clinically the tube remains patent on study with both hystero0020-7292192605.00 0 1992 International Federation Printed and Published in Ireland
salpingography and chromotubation at laparoscopy. Histologically, the mucosa and tubal lumen remain normal despite infestation of tubal serosa and subserosa [6]. Prior cases and series suggest that tubal architecture and patency are maintained despite extensive pelvic adhesions and salpingitis. Complete obliteration of the tubal lumen in the cornual and isthmic portions of the tube and tubal schistosomiasis has not been described. We managed a case of complete proximal tubal obstruction and tubal schistosomiasis by tubocomual anastomosis.
A 31-year-old Filipino female gravida II, para 0, abortus II was referred to the Reproductive Endocrinology Service for consideration of tubal surgery in the management of proximal tubal obstruction (PTO) . After a left salpingectomy for a ruptured ampullary ectopic pregnancy, the patient had a 2-year history of infertility. Six months prior to referral, she underwent evaluation which was notable for a right proximal obstruction documented on both hysterosalpingography and chromotubation at laparoscopy in an otherwise unremarkable evaluation. Her past medical history was significant for a sponCase Report
of Gynecology
and Obstetrics
294
Letterie and Sakas
taneous first trimester abortion and the above noted ectopic pregnancy. There was no history of pelvic inflammatory disease or endometriosis. After referral, fallopian tube canalization under fluoroscopic guidance was unsuccessfully attempted and the patient underwent an exploratory subsequently laparotomy during which chromotubation confirmed a right PTO. At laparotomy, the uterus was of normal size and the left tube was absent consistent with prior surgery. The right cornual region was somewhat paler than the surrounding tissue with a tine miliary appearance to the cornual serosa. The fimbriae of the tube presented tine, filmy adhesions. The patient underwent a right tubocornual anastomosis and timbrioplasty.
Fig. 1.
Low power view (x 10) of proximal
Int J Gynecol Obstet 37
Histologic and histochemical (Fite’s Acid Fast) examination of sections of the resected cornua revealed ova of schistosoma Japonicum in the subsorosal portions of the tube with surrounding fibroplasia and calcitication. The tubal lumen in proximity to the ova revealed complete obliteration and fibrosis. Histologic slides and tissue blocks of the patient’s left tube, previously resected for an ampullary ectopic pregnancy, were recalled, serially sectioned and studied specifically for the presence of ova; none were found. Discussion Proximal tubal obstruction (PTO) is a condition with varied etiologies. The sequelae of
tubal segment showing subserosal
schistosomal
ova (hematoxylin
and eosin).
Proximal tubal obstruction and schistosomiasis
Fig. 2.
High power
view ( x 160) of subserosal
schistosomal
ova (hematoxylin
infection with common pelvic pathogens, obliterative isthmica nodosa, salpingitis fibrosis and endometriosis are the most common histologic changes noted in PTO [3]. However, in one recent series, histologic analysis of resected tubal segments failed to reveal evidence of obstruction or luminal damage in approximately 50% of the cases [7]. PTO with associated with tubal infestation schistosomal ova has not been previously described and represents a unique etiology, particularly relevant to populations where schistosomiasis is endemic. The clinical course and gynecologic sequelae of pelvic schistosomiasis is variable and may range from a minimal inflammatory response to adhesion formation. Such a spec-
295
and eosin).
trum may reflect both the intensity of the parasitic infection and/or a variable host response. Data of this case extend the spectrum of gynecologic abnormalities associated with tubal schistosomiasis to include infertility secondary to proximal tubal obstruction. This case suggests that the clinical course of schistosomiasis may result in the serious sequelae of complete tubal obstruction requiring surgical intervention and may be considered as an etiology of proximal tubal in endemic obstruction and infertility populations. References 1
Bullough CHW: Infertility and bilharziasis of the female genital tract. Br J Obstet Gynaecol 83: 819, 1976. Case Report
296
2
3
4
5 6
Letterie and Sakas
El-Mahgoub S: Pelvic schistosomiasis and infertility. Int J Gynecol Obstet 20: 201, 1982. Fortier KJ, Haney AF: The pathologic spectrum of uterotubal junction obstruction. Obstet Gynecol 65: 93, 1985. Gouvouv A, Baldassini B, Opa JF: Anatomicopathological aspects of genital bilharziasis in women. Med Trop 44: 33 1, 1984. Hassim GM: Tubal gestation associated with schistosomiasis. J Obstet Gynaecol 73: 855, 1966. Okonofua FE, Ojo OS, Odunsi OA, Odesanmi WO: Ectopic pregnancy associated with tubal schistosomiasis. Int J Gynecol Obstet 32: 281, 1990.
Int J Gynecol Obster 37
7 Sulak PJ, Letterie GS, Coddington CC et al: Histology of proximal tubal occlusion. Fertil Steril 48: 437, 1987. 8 Vass ACR: Bilharzial granuloma of the fallopian tube. Case Report. Br J Obstet Gynecol 99: 867, 1982.
Address for reprints: G.S. Letterie Reproductive Endocrinology Service Department of Obstetrics and Gynecology Tripler AMC, Honolulu HI 9689-5000,
USA
293 and Obstetrics
Proximal tubal obstruction schistosomiasis G.S. Letteriea
associated with tubal
and L. Sakasb
“Reproductive Endocrinology Service, Department of Obstetrics and Gynecology and ‘Anatomic Pathology Service, Department oJ’Pathology. Tripler Army Medical Center, Honolulu, Hawaii 96859-5060 (USA) (Received
May 28th.
(Accepted
July 30th, 1991)
1991)
Abstract The gynecologic consequences of schistosomiasis may range from minimal injlammation of tubal serosa to more intense reactions involving the periadnexal regions. Complete obliteration of the tubal lumen has not been described. We describe a case of proximal tubal obstruction associated with tubal schistosomiasis. Keywords:
Proximal Schistosomiasis.
tubal
obstruction;
Case report
Introduction
Schistosomiasis is a disease affecting a variety of organ systems with a wide spectrum of clinical consequences. Sites of pelvic infection include cervix, ovary, vagina and uncommonly, the fallopian tube [4]. In endemic areas, it has been associated with infertility in approximately 60% of the population [l]. Tubal schistosomiasis has been previously implicated in the etiology of ectopic pregnancy, salpingitis and infertility [2,5,8]. Detailed analysis of the sequelae of tubal schistosomal infestation suggest that clinically the tube remains patent on study with both hystero0020-7292192605.00 0 1992 International Federation Printed and Published in Ireland
salpingography and chromotubation at laparoscopy. Histologically, the mucosa and tubal lumen remain normal despite infestation of tubal serosa and subserosa [6]. Prior cases and series suggest that tubal architecture and patency are maintained despite extensive pelvic adhesions and salpingitis. Complete obliteration of the tubal lumen in the cornual and isthmic portions of the tube and tubal schistosomiasis has not been described. We managed a case of complete proximal tubal obstruction and tubal schistosomiasis by tubocomual anastomosis.
A 31-year-old Filipino female gravida II, para 0, abortus II was referred to the Reproductive Endocrinology Service for consideration of tubal surgery in the management of proximal tubal obstruction (PTO) . After a left salpingectomy for a ruptured ampullary ectopic pregnancy, the patient had a 2-year history of infertility. Six months prior to referral, she underwent evaluation which was notable for a right proximal obstruction documented on both hysterosalpingography and chromotubation at laparoscopy in an otherwise unremarkable evaluation. Her past medical history was significant for a sponCase Report
of Gynecology
and Obstetrics
294
Letterie and Sakas
taneous first trimester abortion and the above noted ectopic pregnancy. There was no history of pelvic inflammatory disease or endometriosis. After referral, fallopian tube canalization under fluoroscopic guidance was unsuccessfully attempted and the patient underwent an exploratory subsequently laparotomy during which chromotubation confirmed a right PTO. At laparotomy, the uterus was of normal size and the left tube was absent consistent with prior surgery. The right cornual region was somewhat paler than the surrounding tissue with a tine miliary appearance to the cornual serosa. The fimbriae of the tube presented tine, filmy adhesions. The patient underwent a right tubocornual anastomosis and timbrioplasty.
Fig. 1.
Low power view (x 10) of proximal
Int J Gynecol Obstet 37
Histologic and histochemical (Fite’s Acid Fast) examination of sections of the resected cornua revealed ova of schistosoma Japonicum in the subsorosal portions of the tube with surrounding fibroplasia and calcitication. The tubal lumen in proximity to the ova revealed complete obliteration and fibrosis. Histologic slides and tissue blocks of the patient’s left tube, previously resected for an ampullary ectopic pregnancy, were recalled, serially sectioned and studied specifically for the presence of ova; none were found. Discussion Proximal tubal obstruction (PTO) is a condition with varied etiologies. The sequelae of
tubal segment showing subserosal
schistosomal
ova (hematoxylin
and eosin).
Proximal tubal obstruction and schistosomiasis
Fig. 2.
High power
view ( x 160) of subserosal
schistosomal
ova (hematoxylin
infection with common pelvic pathogens, obliterative isthmica nodosa, salpingitis fibrosis and endometriosis are the most common histologic changes noted in PTO [3]. However, in one recent series, histologic analysis of resected tubal segments failed to reveal evidence of obstruction or luminal damage in approximately 50% of the cases [7]. PTO with associated with tubal infestation schistosomal ova has not been previously described and represents a unique etiology, particularly relevant to populations where schistosomiasis is endemic. The clinical course and gynecologic sequelae of pelvic schistosomiasis is variable and may range from a minimal inflammatory response to adhesion formation. Such a spec-
295
and eosin).
trum may reflect both the intensity of the parasitic infection and/or a variable host response. Data of this case extend the spectrum of gynecologic abnormalities associated with tubal schistosomiasis to include infertility secondary to proximal tubal obstruction. This case suggests that the clinical course of schistosomiasis may result in the serious sequelae of complete tubal obstruction requiring surgical intervention and may be considered as an etiology of proximal tubal in endemic obstruction and infertility populations. References 1
Bullough CHW: Infertility and bilharziasis of the female genital tract. Br J Obstet Gynaecol 83: 819, 1976. Case Report
296
2
3
4
5 6
Letterie and Sakas
El-Mahgoub S: Pelvic schistosomiasis and infertility. Int J Gynecol Obstet 20: 201, 1982. Fortier KJ, Haney AF: The pathologic spectrum of uterotubal junction obstruction. Obstet Gynecol 65: 93, 1985. Gouvouv A, Baldassini B, Opa JF: Anatomicopathological aspects of genital bilharziasis in women. Med Trop 44: 33 1, 1984. Hassim GM: Tubal gestation associated with schistosomiasis. J Obstet Gynaecol 73: 855, 1966. Okonofua FE, Ojo OS, Odunsi OA, Odesanmi WO: Ectopic pregnancy associated with tubal schistosomiasis. Int J Gynecol Obstet 32: 281, 1990.
Int J Gynecol Obster 37
7 Sulak PJ, Letterie GS, Coddington CC et al: Histology of proximal tubal occlusion. Fertil Steril 48: 437, 1987. 8 Vass ACR: Bilharzial granuloma of the fallopian tube. Case Report. Br J Obstet Gynecol 99: 867, 1982.
Address for reprints: G.S. Letterie Reproductive Endocrinology Service Department of Obstetrics and Gynecology Tripler AMC, Honolulu HI 9689-5000,
USA
