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Genital tuberclosis


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Genital tuberclosis

  1. 1.  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.
  2. 2. 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.
  3. 3. 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.
  4. 4. ORGAN FREQUENCY(%) Fallopian tube. 90 - 100 Endometrium. 50 - 60 Ovaries. 20 - 30 Cervix. 5 - 15 Vulva & Vagina. 1
  5. 5. 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.
  6. 6. 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.
  7. 7. Usually bilateral. 2 types:- 1. Perioophoritis. 2. Ophoritis.
  8. 8. 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.
  9. 9. 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.
  10. 10. 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.
  11. 11. 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.
  12. 12. 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.
  13. 13. 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.
  14. 14. Normal in 50%.. Bi manual examination-adenexal mass/fixation of pelvic organs less tender. Abdominal examination-doughy feeling.
  15. 15. CBC, ESR, KFT, CRP CXR Pelvic ultrasound / hystero-salpingography Laparoscopy Histopathology Microbiology:- Mantoux test QTG-T Serology AFB microscopy / culture
  16. 16. EA / EB / EC / menstrual blood Urine – 3 consecutive days (smear vs. culture - St: 52% / 65%; Sp: 89-96 / 100%) Molecular tests HIV
  17. 17. Mantoux QuantiFERON-TB Gold Microscopy Culture Molecular tests – Gen-probe / PCR Identification by Accuprobe FAST Plaque TB
  18. 18. 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%
  19. 19. Ziehl-Neelsen, Kinyoun Fluorochrome - 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/ml Presumptive identification; confirmation by culture / NAA test
  20. 20. 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)
  21. 21. Fully automated Non-invasive Continuously monitored non-radiometric system Revised antibiotic supplement kit Medium - modified Middlebrook 7H9 broth with supplements
  22. 22. CO2 released by mycobacteria detected by sensor Color changes - increase in reflectance units Positive broth - 106-107 orgs/ml Higher biomass - direct inoculation of identification panels & susceptibility tests
  23. 23. In vitro laboratory diagnostic test (May ’05) Indirect test for M. tuberculosis complex M. tuberculosis M. bovis, M. africanum, M. Microti, M. Canetti infection Tuberculosis disease OR latent tuberculosis infection (LTBI)- cannot distinguish between them Intended for use in conjunction with risk assessment, radiography, and other medical and diagnostic evaluations
  24. 24. 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 vaccination Impaired or altered immune function ST: 80-95% (Mantoux 75-90%) SP: 95-100% (Mantoux 70-95%)
  25. 25. DNA probes From cultures Direct samples > 10,000 organisms rRNA probes Gene amplification PCR Isothermal amplification Gen-probe AMTD, NASBA, SDA (IS6110), QB replicase
  26. 26. Uses Rapid diagnosis in smear negative samples 65 kDA protein encoding gene mpt64 gene Differentiate M. tb / NTM Species specific IS6110 Genetic markers for drug resistance Rifampicin – rpoB INH – codon 315 of katG False positives & false negatives (inhibitors) Negative result cannot rule out TB & positive result is not always confirmatory
  27. 27. Based on hybridisation of nucleic acids 4 steps Sample preparation Hybridisation Selection of the hybrid Detection of the hybrid
  28. 28. Mycobacteriophage detection system M. smegmatis lytic cycle: 90 mins Not expensive; safe Viable bacilli, intact phage receptors Affected by effective ATT – monitor trt success Phage inhibitory substances Analytical ST: 100-300 bacilli/ml Mixed results Good sp (96-99%) Less st (70-87%)
  29. 29. Rigid pipe-stem tubes A clubbed ampulla with retort-shaped hydrosalpingx Vascular or lymphatic intravasation of contrast Small shrunken uterine cavity with filling defects Long and dilated cervical canal & dye in cervical crypts Bilateral cornual block Punctate opacification of crypts and diverticulae in lumen of tubes
  30. 30. 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.
  31. 31. 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.
  32. 32. 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.
  33. 33. 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?
  34. 34. 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.
  35. 35. For patients who are compliant and the organism is fully susceptible. INH+RIF+PZA--- 2 months INH+RIF --- 4 months For patients who cannot tolerate PZA INH+RIF--- 9 months Ethambutol 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/thioac etazone
  36. 36. Indications:- Persistent & recurrent disease/pelvic masses/pelvic pain/abnormal bleeding despite adequate treatment Persistent non healing fistula Multi drug resistant disease Concomitant 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.