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Presented By:-
Dr nazima saloda…
GENTAL TUBERCULOSIS…
DIAGNOSIS & TREATMENT…
Genital T.B. 1st recognized by MORGAGNI in 1744.
Incidence in infertility clinics:-
5% in world and 19% in India. 80% – 90% in females aged 20 – 40 years.
INTRODUCTION…
Almost always secondary usually primaries are pulmonary other sites renal, GIT, bone, etc. occasionally part of miliary T.B.
MODE OF SPREAD:- 1. Hematogenous
2. Lymphatic
3. Direct Evidence suggest if primary infection occurs
close to menarche increased chance of genital T.B.
PATHOGENESIS…
HISTOPATHOLOGY…
Tubercular adenitis of mesenteric or pelvic lymph nodes.
Superficial involvement of serosa does not impair reproductive function.
Pelvic T.B. is not the same disease as Genital T.B.
T.B. OF PELVIS…
ORGAN FREQUENCY(%)
Fallopian tube. 90 - 100
Endometrium. 50 - 60
Ovaries. 20 - 30
Cervix. 5 - 15
Vulva & Vagina. 1
FREQUENCY OF T.B. IN ORGANS…
Usually the ampullary region shows the earliest and most extensive changes.
The fimbrial processes become greatly swollen and Ostia remain open or closed.
Gross appearance – 1. TOBACCO POUCH
APPEARANCE.
2. PRODUCTIVE
ADHESIVE FORM.Gross appearance varies and is non-diagnostic.Microscopy, hyperplastic adenomatous pattern may be
confused with adenocarcinoma.
T.B. OF FALLOPIAN TUBES…
Gross size and shape of uterus may appear normal.Endometrium on gross appearance may show
ulcerative, granular or fungating lesion resembling carcinoma.
Endometrial cavity may be obliterated with intrauterine adhesions.
Microscopy classic lesion is the non caseating granuloma.
The granulomatous lesions are best recognized on 24 – 26 cycle days or within 12 hrs. of onset of menses.
T.B. OF ENDOMETRIUM…
Usually bilateral.2 types:- 1. Perioophoritis.
2. Ophoritis.
T.B. OF OVARY…
High degree of suspicion.20% have history of T.B. in immediate family.4 major presenting complaints:-
1. Infertility.
2. Abnormal
bleeding .
3. Pelvic pain.
4.Amennorrhea.
CLINICAL PICTURE…
H/o primary infertility with no apparent cause on examination & family H/o or personal H/o T.B.
H/o vague lower abdominal discomfort with low grade fever/undue fatigue/persistent ill health over months to years associated with weight loss.
Adolescent female presenting with ascites pain and low grade fever.
Menopausal female enlarged uterus that is tense and tender on examination (pyrometra formation)
Recurrent Pelvic inflammatory disease not responding to antibiotic therapy.
CLINICAL SITUATIONS…
Most common initial symptom.
In most large studies:
Infertility presenting c/o in 40% - 50%.
85% never became pregnant & 15%
developed symptoms of genital T.B.
within a year of last pregnancy.
INFERTILITY…
Second common symptom.Pain present for several months which is not usually
severe.M/b associated with swelling of abdomen.Episodes of acute lower abdominal pain owing to
secondary infection by pyogenic org.In advanced disease pelvic pain becomes severe and
gets aggravated by coitus, exercise & mensus.No. of women c/o pain is proportional to no. of women
having abdominal findings on physical examination.
LOWER ABDOMINAL
PAIN…
Third common symptom.Menorragia/ Menometrorragia/ Intermenstrual
bleeding/ Oligomenorrhoea/ Postmenopausal bleeding.
Menstrual cycle may be normal. Superficial T.B. Endometritis does not interfere with secretory response of endometrium to hormonal stimulation.
MENSTRUAL DISORDER…
Advanced active pulmonary T.B. produce amen. but concomitant genital T.B. is rare.
Complete destruction of ovary by genital T.B. seldom occurs so ovarian failure is not the cause.
End organ failure secondary to endometrial caseation.
AMENNORRHOEA…
Normal in 50%..
Bi manual examination-adenexal mass/fixation
of pelvic organs less tender.
Abdominal examination-doughy feeling.
CLINICAL EXAMINATION…
CBC, ESR, KFT, CRPCXRPelvic ultrasound / hystero-salpingography LaparoscopyHistopathologyMicrobiology:-
Mantoux testQTG-TSerologyAFB microscopy / culture
INVESTIGATION…
EA / EB / EC / menstrual bloodUrine – 3 consecutive days (smear vs. culture -
St: 52% / 65%; Sp: 89-96 / 100%)Molecular testsHIV
Mantoux
QuantiFERON-TB Gold
Microscopy
Culture
Molecular tests – Gen-probe / PCR
Identification by Accuprobe
FAST Plaque TB
MICROBIOLOGICAL TEST…
Diagnostic role of a positive Mantoux (PPD) is controversial
Almost 45% of infertile women with strong indirect evidence of pelvic TB, such as laparoscopic findings (thickened tubes, areas of caseation, etc) - negative Mantoux
In 27 infertile women with a positive Mantoux, only 11 had clear laparoscopic findings suggestive of FGTB
Mantoux test in women with laparoscopically diagnosed tuberculosis sensitivity - 55% specificity - 80%
MANTOUX TEST…
Ziehl-Neelsen, KinyounFluorochrome - Auramine-rhodamine (direct
fluorescence)Higher sensitivity; faster screening
ST: 22-78% (cf culture)MC Detection limit in sputum: 5000-10000 orgs/ml
Culture: 100 orgs/mlPresumptive identification; confirmation by culture /
NAA test
MICROSCOPY…
Decisive step for diagnosis, treatment & control of TB
Combination of solid & liquid media- “gold standard” for primary isolation
Recommended turn around time (CDC)14 days (culture)21-30 days (identification & susceptibility)
CULTURE…
Fully automated
Non-invasive
Continuously monitored non-radiometric
system
Revised antibiotic supplement kit
Medium - modified Middlebrook 7H9 broth
with supplements
BacT/ALERT 3D MB…
CO2 released by mycobacteria detected by sensorColor changes - increase in reflectance unitsPositive broth - 106-107 orgs/ml
Higher biomass - direct inoculation of identification panels & susceptibility tests
In vitro laboratory diagnostic test (May ’05)Indirect test for M. tuberculosis complex
M. tuberculosisM. bovis, M. africanum, M. Microti, M. Canetti
infectionTuberculosis disease OR latent tuberculosis infection
(LTBI)- cannot distinguish between themIntended for use in conjunction with risk assessment,
radiography, and other medical and diagnostic evaluations
QUANTIFERON-TB GOLD…
Single patient visit - whole blood sample - 4 ml of heparinised whole blood
Must be transported to lab to allow initiation of testing within 12 hours (viable lymphocytes)
Rapid results (within 24 hours)No booster response (measured by subsequent tests -
which can happen with Mantoux)No reader bias (cf Mantoux)Not affected by prior BCG vaccinationImpaired or altered immune functionST: 80-95% (Mantoux 75-90%)SP: 95-100% (Mantoux 70-95%)
DNA probesFrom culturesDirect samples > 10,000 organisms
rRNA probesGene amplification
PCRIsothermal amplification
Gen-probe AMTD, NASBA, SDA (IS6110), QB replicase
MOLECULAR DIAGNOSIS OF TB...
UsesRapid diagnosis in smear negative samples
65 kDA protein encoding genempt64 gene
Differentiate M. tb / NTMSpecies specific IS6110
Genetic markers for drug resistanceRifampicin – rpoBINH – codon 315 of katG
False positives & false negatives (inhibitors)Negative result cannot rule out TB & positive result is
not always confirmatory
PCR…
Based on hybridisation of nucleic acids4 steps
Sample preparationHybridisationSelection of the hybridDetection of the hybrid
ACCUPROBE TEST…
Mycobacteriophage detection systemM. smegmatis lytic cycle: 90 minsNot expensive; safeViable bacilli, intact phage receptorsAffected by effective ATT – monitor trt successPhage inhibitory substancesAnalytical ST: 100-300 bacilli/mlMixed results
Good sp (96-99%)Less st (70-87%)
FASTPlaque TB…
Rigid pipe-stem tubesA clubbed ampulla with retort-shaped
hydrosalpingxVascular or lymphatic intravasation of contrastSmall shrunken uterine cavity with filling defectsLong and dilated cervical canal & dye in cervical
cryptsBilateral cornual blockPunctate opacification of crypts and diverticulae
in lumen of tubes
HSG…
A combination of PCR with the other available techniques is the best method of achieving sufficient sensitivity and specificity for the diagnosis of female genital tuberculosis
PCR positive + culture negative – warrants therapy as PCR can detect very few bacilli & even dead bacilli.
PCR negative + culture positive – this result cannot be dismissed as contamination carry false negative rate of PCR. Culture remains gold standard.
CONCLUSION…
Clinical:• Acute and chronic bacterial infection.• Ascites / peritonitis / hepatitis/ chloecystitis /
appendicitis / ovarian / cancer/ renal dz / cardiac dz.
HPR: Granulomatous lesion- Sarcoidosis / leprosy
/ syphilis / FB reaction.
DIFFRENTIAL DIAGNOSIS…
Subfertility & Infertility- Residual damage of the fallopian tubes is often irreversible even following medical regimens, unless genital T.B. is diagnosed and treated early in its course. Symptoms of pain and menstrual disorder respond to medical treatment.
Ectopic pregnancy- Risk of ectopic pregnancy following medical treatment is estimated to be 33%- 72%.
Congenital T.B.- Rare but potentially serious complication. Over whelming systemic infection in the new born has considerable morbidity &mortality.
COMPLICATIONS…
Once diagnosed a gynecologist must consider following points:- Rule out active T.B. at any other site.Know the extent of genital lesion.Will medical management cure the lesion?Is pregnancy possible following treatment?
MANAGEMENT…
Experts suggest that it is easier to treat these cases because they are paucibacillary.
3 basic principles for chemotherapy for T.B.Regimen must contain multiple drugs to which
organism is susceptible.Drugs are to be taken regularly.Drugs should continue for a sufficient period of
time.
MEDICAL TREATMENT…
For patients who are compliant and the
organism is fully susceptible.
INH+RIF+PZA--- 2 months
INH+RIF --- 4 monthsFor patients who cannot tolerate PZA
INH+RIF--- 9 monthsEthambutol or SM should be included in above
regimen till results of drug susceptibility are
available.Add pyridoxine 25-50mg in regimen including
INH.Multi drug resistance drug used are-PAS/cycloserine/capreomycin/kanamycin/amikacin/thioacetazone
Indications:-Persistent & recurrent disease/pelvic masses/pelvic
pain/abnormal bleeding despite adequate treatmentPersistent non healing fistulaMulti drug resistant diseaseConcomitant neoplasia of genital tract
Chemotherapy should precede surgery by 1-2 weeks.Surgery should be done at mid cycle in premenopausal.C.T. should be continued for 6-12 months post op.Premenopausal-save ovaries if normal, otherwise TAH
with BSO followed by HRT.
SURGICAL TREATMENT
Thank
you….