2019 Research Forum

Applicant & Principal Investigator: Roxanne McDermott MD R4 Faculty Sponsor: Antonio Garcia MD FACOG Granulomatous Disease Using the Pathway of Sampson’s Theory of Retrograde Menstruation to Infect the Abdomen

Roxanne McDermott MD R4, Antonio Garcia MD FACOG, Victoria Flores MD R3

INTRODUCTION Granulomatous diseases of the abdomen have been reported as beginning in the fallopian tubes; however, this disease has not yet been reported in the medical literature as originating in the endometrium and traveling into the abdomen in a similar pathway to pelvic inflammatory disease or retrograde menstruation (Sampson’s theory). A 46yo female pt presented to the ER multiple times with complaints of bloating and generalized abdominal and pelvic pain as well as abnormal uterine bleeding. She had recent unintentional weight loss, an elevated CA 125, ovarian masses, and diffuse ascites. She was taken back to the operating room by gynecology oncology who performed a TAH, BSO, and omentectomy for suspected ovarian cancer. She was instead found to have diffuse granulomatous peritonitis with pathology showing possible sarcoid versus miliary tuberculosis. All acid fast stains were negative. The pathology showed granulomatous peritonitis with negative acid fast and fungal stains, unable to exclude sarcoidosis. Of note, the pathologist comments that the scattered granulomata were noted within the lamina propria of the fallopian tubes with peritoneal spread. This direction of spread is unique and only seen normally with endometriosis, per Sampson’s theory of Retrograde menstruation. PURPOSE The purpose of this study is report a unique case of granulomatous disease of the endometrium that traveled to the patient’s abdomen in a manner similar to a sexually transmitted infection through the fallopian tubes. Sampson’s theory of retrograde menstruation further supports this pathway. Most cases of granulomatous disease begin in the fallopian tubes, not the endometrium as the pathology states in this case. The IRB review for this case is being submitted. DISCUSSION Granulomatous disease of the pelvic organs usually is reported as beginning in the fallopian tubes. In this unique case, the disease process began in the endometrium and gained access to the abdomen through the fallopian tubes similar to sexually transmitted infections. The patient presented to the hospital with what was believed to be advanced ovarian cancer and had an exploratory laparotomy. Intra-operatively she was discovered to have military disease of the abdomen that was found to be benign on frozen pathology. The pathology report of the case states that the granulomatous lesion began in the endometrium and traveled through into the abdomen through the fallopian tubes with the suggestion of douching, which the patient denies engaging in. Sampson’s theory of retrograde menstruation offers an alternative pathway during which the menstrual cycle of this patient would allow the disease to travel through the fallopian tubes and into the abdomen. CONCLUSION This case offers a unique situation during which a granulomatous disease began in the endometrium and traveled through the fallopian tubes, possibly during the patient’s menstrual cycle, and into the abdomen to affect her entire pelvic and abdominal cavity. Previous case reports have shown the fallopian tubes and the first area affected in granulomatous diseases like tuberculosis; however, this is one of the first reports to show the initial lesion as in the endometrium with a unique pathway traveled to enter the abdomen. The theory follows a spread seen only with endometriosis per Sampson’s theory of retrograde menstruation.

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