2019 Research Forum

Roxanne McDermott MD R4, Victoria Flores MD R3, Antonio Garcia MD Granulomatous Disease Using the Pathway of Sampson’s Theory of Retrograde Menstruation to Infect the Abdomen

Introduction

Case Presentation

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). tubes with peritoneal spread. This direction of spread is unique and only seen normally with endometriosis, per Sampson’s theory of Retrograde menstruation.

A 46yo female pt presented to the ER multiple times with complaints of bloating and generalized abdominal and pelvic pain with 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. Intraoperatively, she had diffuse granulomatous peritonitis with pathology showing possible sarcoid versus miliary tuberculosis. 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.

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. .

Purpose

Conclusions

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.

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 number for this case is 19027.

Acknowledgements

References

Loremips EfaredB, Sidibe,Erragad.Femalegenital tuberculosis:a clinicopathologicalreportof13 cases. J SurgCaseRep.2019Mar23;2019(3):rjz0 SachanR,PatelM,GuptaPetal.Genital tuberculosiswithvariablepresentation:a seriesof threecases.BMJCaseRep.2012;2012:bcr2012006665 MarakCP,NarendrakumarA,etal.UterineSarcoidosis:A rareextrapulmonarysiteof sarcoidosis.CaseReports inRheumatology.2013 PearceKF,NolanTE.Endometrial sarcoidosisasa casueofpostmenopausalbleeding.A case report. JReprodMed.1996Nov;41(11):878-80 DiCarloFJ,DiCarloJP,RobboySJ, Lyons,Sarcoidosisof theuterus,ArchPatholLabMed.1989Aug;113(8):941-3

Thank you to my husband Joe McDermott for supporting me through this research process. Thank you to Joan for all of her help through the IRB process, also to Dr. Varnes for his help submitting the documents when I was away.

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