Case notes
A gravida zero patient in her mid twenties, originally from Ethiopia with no known history of tuberculosis, had primary amenorrhea. Her initial investigations included an ultrasound scan and sonohysterogram that showed no distension of the fundal aspect of the endometrial cavity, 2 uterine horns, and bilateral hydrosalpinges with calcifications. An endometrial biopsy revealed necrotizing well-formed granulomas. Formal workup confirmed calcified granulomas in the right middle lobe and calcified lymph nodes consistent with tuberculosis. Lymph node biopsy and sputum culture confirmed the diagnosis. She was started on isoniazid, rifampin, and pyrazinamide for 6 months.
After therapy, imaging was repeated. Computed tomography demonstrated bilateral peripheral tubal calcifications ( Figure 1 ). Magnetic resonance imaging confirmed tubal calcifications with complex debris and the presence of a septate uterus ( Figure 2 ). The decision was made to proceed with surgical management based on her ongoing amenorrhea and the magnetic resonance imaging findings. The laparoscopic view showed tubes that were dilated with solid material and blocked proximally; her distal tubes and uterine contour appeared normal ( Figure 3 ). At hysteroscopy, the left tubal ostium was visualized, but the right uterine horn was fused completely. Attempts were made to release that side of the cavity but were abandoned. The patient has relocated to a different city where she currently is pursuing fertility assessment and treatment.
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