female genital TB poses stiffest challenge in the diagnosis, rapid molecular techniques have helped in arriving at a definitive diagnosis in suspicious clinical setting

1. Veerendrakumar C M
MD,DNB
Professor
Dept of Obstetrics and Gynecology
VIMS,Bellary
veerendrakumarcm@gmail.com

2.  TB recognized as clinical entity in 1000BC
 Morgagni postmortem examination of a
WOMAN IN 1744 , Her uterus tubes filled with
caseous material..
 TB word coined in 1834
 Robert Koch discovered bacilli in 1884

3. Indonesia
6%
Nigeria
5%
Other countries
20%
Other 13 HBCs
16% China
14%
South Africa
5%
Bangladesh
4%
Ethiopia
3%
Pakistan
3%
Phillipines
3%
India
21%
Global annual incidence = 9.4 million
India annual incidence = 1.96 million
India is 17th among 22
High Burden Countries
(in terms of TB
incidence rate)

4. Estimated burden per year
 Indirect costs to society $3 billion
 Direct costs to society $300 million
 Productive work days lost due to TB illness 100 million
 Productive work days lost due to TB deaths 1.3 billion
 School drop-outs due to parental TB 300,000
 Women rejected by families due to TB 100,000

5.  50% of Indian Population has TB
 Every one minute one person dies of TB

6.  Mostly secondary manifestation of
Primary Tb
 5-13% of PTB develop into GTB
 Genital tract vulnerable after puberty

7.  Meningeal TB gravest manifestation
 Genital TB poses stiffest diagnostic
challenge.

8.  Varied clinical presentation
 diverse results on
imaging,
laparoscopy,
HPE and
mixed bag of bacteriological and
serological tests.

9.  Disease discovered incidentally
 Physician’s interest in searching for the
disease
Fransis J obstet gynecol Br Commonw 1964

10.  5% incidence world wide
 < 1% in USA
 19% in India
 Cli obstet gynecol 1976

11.  Frequency of Genital TB in surgically
removed adnexa 2-20%
 Depends on care with which
examination done..

13.  Infertility cases 17.8%
Khilani et al 1988
 GTB -3.5%
Ojo et al 1966
 Gini from nigeria reported 0.2%
Int J obstet gynecol 1990

14.  GTB a major health problem in
developing countries.
Am J obstet Gynecol 1990

15.  Almost always secondary to primary Tb
elsewhere in the body.
 If bacilli not eradicated may get reactivated
later in life esp in the presence of
- Hodgkin’s Lymphoma
- AIDS
-Steroids
- Stress
- Malnutrition

16.  Fallopian TB most favorable nidus with
earliest lesion in Mucosa

17.  Bovine genital tuberculosis may spread
thru GIT by drinking raw milk.

18.  When primary infection occurs closer to
Menarche
genital tract more likely to be involved.
Burnie 1956

19.  Sexual partners may be source of infection
 4% of husbands had active genitourinary
TB
Sutherland 1982

20.  May exist as adenitis of mesenteric or pelvic
lymphnodes.
 May not involve genital tract

21. ORGAN FREQUENCY
Fallopian tubes 90-100%
Endometrium 50-60%
Ovaries 20-30%
Cervix 5-15%
Vulva and Vagina 1%
Schaefer 1976

22.  Exudative salpingitis – acute phase
 Adhesive salpingitis- studded with
tubercles and densely adherent to
adjacent organs.

24.  Further involvement of uterus and
ovaries by direct spread
 Most extensive TB involvement in the
fundus
 Shed endometrium is reinfected from
the tubes.

25.  Total destruction of the endometrium
can result in amenorrhea (2.5% cases of
TB endometritis)
Obstet gynecol 1979
Fertil steril 1982

26. Infrequent,extremely scanty, isolated,
scattered small tubercles are seen.
Careful search thru all the curettings may
show 1-2 foci TB !!!!

27.  Granuloma are best recognised on Day
24-26
 Or within 12 hrs of the onset of menses.
Fertil steril 1978

28.  Plastic variety
- less common, tender abdominal mass,
“doughy” to palpation
 Serous variety
more common, ascites,fever , wt loss ,
anorexia

29.  66 % women were between 25-35 yrs
11% were postmenopausal
Obstet gynecol 1979
 In recent times incidence in older women
is increasing..
Sutherland 1982

30.  High index of suspicion
 20% give family history
 30-50% might have had some form of TB
and give H/o ATT.
Int J Obstet Gynecol 1991

31.  Systemic
 Infertility
 Menstrual disturbances
 Abdominal swelling , postcoital bleeding,
vaginal discharge,dyspareunia

32.  Infertility
 AUB
 CPP
 Amenorrhea

33.  85% of GTB patients were never
pregnant
 Infertility is the leading complaint in
50% Sutherland AM 1983
 64% complained of infertility
Tripathy ,JIMA 1987

34.  25-50%
 Chronic in nature
 May get aggravated by
coitus,exercise,menses

35.  Oligohypomenorrhea -54%
 Menorrhagia – 20%
 Amenorrhea – 14 %
JIMA 2000
 High degree of suspicion and efficient
investigation

36.  Endorgan failure due to caseation
 Ovary function normally
Malkani et al 1966

37. Poor health
Wt loss
Undue fatigue
Low grade fever
Vague abdominal discomfort

38.  Uterovesical,tubointestinal,tuboperitoneal
fistula may be present
 GTB can mimick ovarian malignancy
 Ca 125 can also be raised
 Sheth SS Int J obstet Gynecol 1996

39.  Normal 35- 50 %
 Abdominal mass
 Pelvic mass
 Adnexal mass/ tenderness
 Ascites
 Excessive Vaginal discharge
 Ulcer vagina cervix vulva
Simon et al Am J Med 1977

40.  Superimposition of bacterial infection,
gynecological operative procedures
trauma to the pelvis
Am J obstet gynecol 1972

41.  in postmenopauasal women
 Senile endometritis
ca cervix
J clin Ultrasound 1983

42.  Unexplained infertilty
 Chronic PID refractory to standard
antibiotic treatment
 Adnexal disease with ascites in virgins

43.  Little value
 Counts usually normal, tendency towards Rt
side
 Urine microscopy may show abacteriuric
pyuria in concommitant GUTB
Burnie 1956

44.  Egg based media 3-8 weeks
eg Lowenstein Jensen media
 Agar based < 3 weeks
eg- BACTEC medium
 BacT/ALERT 3D MB
 modified Middlebrook 7H9 broth with
supplements

45.  Prior evidence of Pulmonary TB may be
present in 10- 50% of the cases
 Simultaneous active PTB and GTB are rare.
Chattopadhyaya 1986

46.  Not 100 % sensitive
or specific
 A positive test is read
as discrete wheal
> 10mm between 48 -
78 hrs

47.  Mantoux test in women with
laparoscopically diagnosed tuberculosis
sensitivity - 55% specificity - 80%
Int J Gynaecol Obstet 2001

48.  Endometrium readily accessible
 < 12 hrs collection showed positive for MTB
in 10% of the cases.
 Other AFB may be mistaken for MTB
NTM -non tubercular mycobacteria
MOTT- mycobacteria other than tubercular

49.  Frequent first diagnostic test
 False negetive bcoz of sampling errors
 Diagnosis either MTB isolation or
histological Granulomata.

50.  Cornual curettage yields atleast 50%
possibilty of rapid histological diagnosis
 Optimum time late menses period or < 12
hrs of menses
 positive culutre was seen in 25 % cases of
Tb endometritis.
Am J Obstet gynecol 1980

51.  110 cases of endometrial sampling
 13.6% culture
 Smear positive in 1.8% cases
 HPE in 3.6% cases
Albert H 1990

52.  Avoid if TB is suspected , exacerbation
following the procedure.
Winifred 1977

60.  Irregular uterine cavity
 Intrauterine adhesions
 Scanty endometrium
 Endometrial calcification
 Caseation/ tubercles
 Periosteal fibrosis
 Caseous material coming out of ostia
 Ostia not visualized
JIMA july 2013

62. ADHESIONS AFTER ADHESIOLYSIS

64. Normal ostia Intrauterine adhesions

66.  Adhesions
 Pelvic congestion
 Tubercles
 Frozen pelvis
 Edematous inflammed tubes
 Beaded tubes
 TO mass
 Straw colored fluid inPOD
JIMA july 2013

67.  Conventional cultures take 3-8 weeks to
yield definitive result.

68.  Genotypic Methods :
 PCR
 NAA
Dr.T.V.Rao MD 68

69.  Detection is based on multiplication not of
whole bacilli, as in culture, but of their genetic
material, chromosomal DNA or ribosomal RNA.
 In principle, from one target sequence, of one
bacillus, the reaction can produce millions of
copies and thus yield a positive result
Dr.T.V.Rao MD 69

73.  in principle, only 1-2
days are needed.
Dr.T.V.Rao MD 73

74.  Gen –probe M.tuberculosis test –
transcription mediated amplification of
rRNA
good in smear positive samples
 Ampiclor test – PCR amplification of DNA

75.  Real time PCR
eg: Mycosure Dr.Lal Pathlab
detects both mycobacterium tuberculosis and
Non tuberculosis mycobacteria
 Multiplex PCR
eg TB PCR –SRL laboratory
detects mycobacteria tuberculosis complex

76.  Nested DNA PCR
Eg. Reliance laboratory
targets IS61110 gene region in TB DNA

77.  False positive PCR may be due to NTM
 False negative due to
sampling error
blood contamination
paucibacillary specimens
PCR inhibitors
ineffective primers

79.  Repeat tissue sampling
 Go for different diagnostic technique

83.  new class of in vitro
assay that measure
interferon (IFN-γ)
released by sensitized T
cells after stimulation
by M. tuberculosis
antigens.
 Measures immune
reactivity to M.tb.
83

84.  provide the best
available method of
diagnosing TB
infection using blood.
 Used for screening..
84

85.  QuantiFERON-TB ® test
– Commercially available.
– Measures amount of IFN-γ produced. (ELISA)
– FDA-approved for the detection of LTBI, 2001.
85

86.  Initial therapy with 4 drugs
INH+RIF+PZA
add EMB/SM
 Maintenance therapy
INH +RIF

88.  Histologically cured between 4-12 weeks
 Recurrence of cases within 2-5 yrs if
tubes are not removed.
Kardos et al

89.  Careful compliance is the most important
to prevent drug resistance

90.  Persistent /recurrent disease
 Recurrent pelvic masses
 Recurrent pelvic pain and AUB
 Non healing fistula
 Concomittant neoplasia

91.  Start ATT immediately for 6-12 months

92.  Sutherland 1976 – 6.7% livebirth rate
206 women treatment for 18-24 months 26
conceived
23 live births,11 ectopic, 11 miscarriage
 Tripathy-2006
Conception rate 19.2% livebirth rate- 7.2%

93.  BETTER chance of conception
Frydman et al - 49 attempts 6 conceived

94.  FGTB underdiagnosed.
 Strong suspicion is key to diagnosis
 Prompt treatment of primary TB decreases
incidence of EPTB
 Routine blood tests, Mantoux test, smear, histology
and culture pick up very low % cases
 Modern NAAT tests are rapid and help in the
diagnosis and treatment
 Infertility with poor pregnancy rate is seen in FGTB.