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female genital tuberculosis, clinical approach

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F:\งาน Powerpoint And Word\Fgtb2010

  1. 1. Journal club Vichaiyut Hospital Obstetrics and Gynecology April 2010 Viriya Lekprasert,obgyn,18745
  2. 2. Female genital tuberculosis <ul><li>Review from www.rcog.org.uk </li></ul><ul><li>2005 ; 7 : 75 – 79 </li></ul><ul><li>David K Gatongi , et al . , UK </li></ul>Viriya Lekprasert,obgyn,18745
  3. 3. <ul><li>TB exists in two forms : pulmonary and extrapulmonary. ( extra. is 40% of all TB ) </li></ul><ul><li>Genital TB represents 15 – 20 % of extrapulmonary TB </li></ul><ul><li>Affect 1.5 / 100,000 inhabitants in the UK </li></ul>Viriya Lekprasert,obgyn,18745
  4. 4. <ul><li>Mycobacterium tuberculosis accounts for 90 – 95 % of genital TB. </li></ul><ul><li>M. bovis , 5 – 10 % ( from GI tract ) </li></ul>Viriya Lekprasert,obgyn,18745
  5. 5. How to reach genital tract <ul><li>TB reach genital tract by 3 routes : </li></ul><ul><li>1. hematogenous </li></ul><ul><li>2. direct spread </li></ul><ul><li>3. primary infection </li></ul>Viriya Lekprasert,obgyn,18745
  6. 6. Hematogenous spread <ul><li>About 90 % of cases </li></ul><ul><li>Primary focus being the lung , </li></ul><ul><li>lymph nodes , skeleton system </li></ul>Viriya Lekprasert,obgyn,18745
  7. 7. Descending direct spread <ul><li>Via the lymphatic system </li></ul><ul><li>or directly from GI tract , mesenteric nodes , </li></ul><ul><li>or the peritoneum </li></ul>Viriya Lekprasert,obgyn,18745
  8. 8. Primary infection <ul><li>from sexual intercourse , ascending spread from vulva , vagina ( 1 % ) , cervix ( 5 – 15 % ) to upper tract </li></ul><ul><li>Fallopian tubes 95 – 100 % </li></ul><ul><li>Endometrium 50 – 60 % </li></ul><ul><li>Ovaries 20 – 30 % </li></ul><ul><li>Myometrium 2.5 % </li></ul>Viriya Lekprasert,obgyn,18745
  9. 9. Presenting SYMPTOMS <ul><li>Infertility </li></ul><ul><li>Oligomenorrhrea </li></ul><ul><li>Amenorrhea </li></ul><ul><li>Menorrhagia </li></ul><ul><li>Abdominal pain </li></ul><ul><li>Dyspareunia </li></ul><ul><li>dysmenorrhea </li></ul>Viriya Lekprasert,obgyn,18745
  10. 10. Diagnosis <ul><li>Should be considered in high risk </li></ul><ul><li>1. unexplained infertility </li></ul><ul><li>2. unexplained amenorrhea </li></ul><ul><li>3. pelvic infection not respond to treatment </li></ul><ul><li>4. postmenopausal bleeding , leukorrhea , pyometra excluded neoplasia </li></ul>Viriya Lekprasert,obgyn,18745
  11. 11. Investigation <ul><li>Tuberculin test in genital tuberculosis </li></ul><ul><li>sensitivity of 50 % </li></ul><ul><li>specificity of 80 % </li></ul><ul><li>false negative 20 % </li></ul><ul><li>* HIV infection and corticosteroid therapy may cause false positive </li></ul>Viriya Lekprasert,obgyn,18745
  12. 12. Investigation ( cont. ) <ul><li>Chest X-ray is aimed at demonstrating lesion in the lungs , however , most CXRs are normal </li></ul><ul><li>Specimens / tissue for culture or histology : endometrial tissue , menstrual fluid , lesion on tubes - ovaries - adnexae </li></ul>Viriya Lekprasert,obgyn,18745
  13. 13. Investigation ( cont. ) <ul><li>Rapid nucleic acid amplification techniques </li></ul><ul><li>: PCR , can detect fewer than 10 organisms , compared with 10,000 necessary for smear . </li></ul><ul><li>: sensitivity 85 - 95 % </li></ul>Viriya Lekprasert,obgyn,18745
  14. 14. Imaging <ul><li>USG , CT , MRI are employed in </li></ul><ul><li>circumstances where mass is present and </li></ul><ul><li>useful in the presence of ascites . </li></ul>Viriya Lekprasert,obgyn,18745
  15. 15. Imaging ( cont. ) <ul><li>HSG is performed frequently for infertility </li></ul><ul><li>, should not be performed where TB is </li></ul><ul><li>diagnosed by other means , it may </li></ul><ul><li>dissemination and flare-up of disease. </li></ul>Viriya Lekprasert,obgyn,18745
  16. 16. Treatment <ul><li>6 months regimens including 4 drugs in the initial phase ( first 2 months ) </li></ul><ul><li>- rifampicin </li></ul><ul><li>- isoniazid </li></ul><ul><li>- pyrazinamide </li></ul><ul><li>- ethambutol </li></ul><ul><li>followed by rifampicin and isoniazid </li></ul>Viriya Lekprasert,obgyn,18745
  17. 17. Side effect of anti-TB drugs <ul><li>Isoniazid and rifampicin both are </li></ul><ul><li>associated with hepatitis , cutaneous </li></ul><ul><li>hypersensitivity and hemolytic anemia </li></ul><ul><li>Isoniazid may cause peripheral </li></ul><ul><li>neuropathy </li></ul>Viriya Lekprasert,obgyn,18745
  18. 18. Side effect ( cont. ) <ul><li>Pyrazinamide causes anorexia , nausea , hepatitis , arthralgia and hyperuricaemia </li></ul><ul><li>Ethambutol is associated with retrobulbar neuritis , hepatitis and peripheral neuropathy </li></ul>Viriya Lekprasert,obgyn,18745
  19. 19. After treatment <ul><li>Relapse is seen in 0-3 % </li></ul><ul><li>Conception rate 19 % </li></ul><ul><li>Live birth rate 7.2 % </li></ul><ul><li>Increase in ectopic pregnancy and miscarriage rate </li></ul>Viriya Lekprasert,obgyn,18745
  20. 20. Tuberculin test (PPD test) ( review from Wikipedia ) <ul><li>2009 , American Thoracic Society , Center Disease Control and prevention : </li></ul><ul><li>- conversion test is defined as “positive” within a 2-year period </li></ul><ul><li>- ppd test is not contraindicated for BCG-vaccinated persons and prior BCG vaccination </li></ul>Viriya Lekprasert,obgyn,18745
  21. 21. PPd test ( cont.) <ul><li>2009 , US guidelines : latent TB diagnosis and treatment is considered for BCG vaccinated person whose ppd test positive </li></ul><ul><li>If the first test is negative , give second test 1 – 3 wk. after first injection </li></ul>Viriya Lekprasert,obgyn,18745
  22. 22. PPD test (cont.) <ul><li>September 28, 2008 , Centers for Disease Control and Prevention ( NY Times Health ) </li></ul><ul><li>“ past BCG vaccination should not chage the PPD result when the test is done 15 years after the vaccination “ </li></ul>Viriya Lekprasert,obgyn,18745
  23. 23. Incidence of FGTB <ul><li>2005, UK 0.0015 % </li></ul><ul><li>2003 , Dpt. Ob.-Gyn., Maulana Azad Medical College, India 0.75 – 1 %. ( 2008, prevalence 1-19 % ) </li></ul><ul><li>2002, Dpt. Ob.-Gyn., University Malaya Medical Center, Malaysia 0.03 % </li></ul>Viriya Lekprasert,obgyn,18745
  24. 24. Incidence of FGTB (cont.) <ul><li>1999, NY Methodist Hospital 0.02 % </li></ul><ul><li>1993, Dpt. Ob.-Gyn., Kwong Wah Hospital , HK 0.06 % </li></ul><ul><li>1980, Swedish Hospital 0.02-0.05 % </li></ul>Viriya Lekprasert,obgyn,18745
  25. 25. <ul><li>J Med Assoc Thai January 1999 , </li></ul><ul><li>Ramathibodi Hospital , reported incidence </li></ul><ul><li>FGTB 0.01 % of OPD cases , 0.05 % of </li></ul><ul><li>IPD cases </li></ul>Viriya Lekprasert,obgyn,18745
  26. 26. <ul><li>From January 2003 to January 2007 , </li></ul><ul><li>12,497 cases of my gynecological patients, </li></ul><ul><li>8 pt., high suspicion clinical FGTB, 0.06 % </li></ul>Viriya Lekprasert,obgyn,18745
  27. 27. High suspicion clinical FGTB <ul><li>Case 1 : Thai female, 33 yr., G1P0A1 </li></ul><ul><li>: multiple,recurrent PID </li></ul><ul><li>: ppd test pos ., 01 May 2003 </li></ul><ul><li>: CXR negative </li></ul><ul><li>: counselling for anti-TB drugs </li></ul>Viriya Lekprasert,obgyn,18745
  28. 28. High suspicion clinical FGTB <ul><li>Case 2 : Th.female, 36yr., G1P0A1 </li></ul><ul><li>contact pulmonary TB, </li></ul><ul><li>multiple recurrent batholinitis and abcess, </li></ul><ul><li>ppd test 24 Sep 2004 neg . </li></ul><ul><li>(prior neg. 21 MAY 1997) </li></ul>Viriya Lekprasert,obgyn,18745
  29. 29. High suspicion clinical FGTB <ul><li>Case 2 (cont.) : 29 Sep 2005, abortion </li></ul><ul><li>8 Nov 2005, bilat. Batholin abcess, ppd test pos. </li></ul><ul><li>20 Jun 2006, pt. requested repeat ppd test, NEGATIVE </li></ul>Viriya Lekprasert,obgyn,18745
  30. 30. High suspicion clinical FGTB <ul><li>Case 3 : Th.female, 26yr., chronic pelvic pain, underlying endometriosis </li></ul><ul><li>Constitutional symptoms : lethargy, weight loss </li></ul><ul><li>Prior ppd, 2004, neg. </li></ul><ul><li>13 Dec 2005, ppd positive </li></ul>Viriya Lekprasert,obgyn,18745
  31. 31. High suspicion clinical FGTB <ul><li>Case 4 : Th.female, 21yr., share sexual partner </li></ul><ul><li>Multiple recurrent PID, condyloma,CIN 1 </li></ul><ul><li>PPD positive, 28 Nov 2005 </li></ul>Viriya Lekprasert,obgyn,18745
  32. 32. High suspicion clinical FGTB <ul><li>Case 5 : Th.female, 22 yr., share sexual partner with case 4 . </li></ul><ul><li>Multiple recurrent PID, prior pulmonary TB 3 yr. ago, complete treatment </li></ul><ul><li>20 Dec 2005, ppd pos. </li></ul>Viriya Lekprasert,obgyn,18745
  33. 33. High suspicion clinical FGTB <ul><li>Case 6 : Th.female, 26 yr., </li></ul><ul><li>recurrent PID </li></ul><ul><li>07 Jan 2007, ppd pos. </li></ul>Viriya Lekprasert,obgyn,18745
  34. 34. High suspicion clinical FGTB <ul><li>Case 7 : Th.female 30 yr., G1P1A0 </li></ul><ul><li>Recurrent PID , metrorrhagia with pelvic pain , try pregnancy </li></ul><ul><li>16 Feb 2004, ppd neg. </li></ul><ul><li>12 Jan 2006, ppd pos. , Second opinion </li></ul><ul><li>17 Apr 2006, mom-in-law was pulmonary TB </li></ul><ul><li>19 Apr 2007, revisit; 12 March 2008, pregnancy </li></ul>Viriya Lekprasert,obgyn,18745
  35. 35. High suspicion clinical FGTB <ul><li>Case 8 : Th.female, 30 yr., recurrent vaginitis , PID </li></ul><ul><li>17 Mar 2004, ppd pos. </li></ul>Viriya Lekprasert,obgyn,18745
  36. 36. QuantiFERON-TB (QFT), CDC guidelines, 2005 Dec. <ul><li>QFT is indicated for diagnosing infection </li></ul><ul><li>with M. tuberculosis </li></ul><ul><li>including both TB disease and latent TB </li></ul>Viriya Lekprasert,obgyn,18745
  37. 37. QFT( cont.) <ul><li>Used in all circumstances in which the ppd is used. </li></ul><ul><li>Positive QFT, interventions as a positive ppd. </li></ul><ul><li>Specificity 97.7%, sensitivity 67% </li></ul><ul><li>( ppd :spec.80%, sens.50%) </li></ul>Viriya Lekprasert,obgyn,18745
  38. 38. High suspicion clinical FGTB with QFT positive <ul><li>Th. Female, 39 yr., G1P1A0 </li></ul><ul><li>Recurrent vaginitis </li></ul><ul><li>Ppd test positive </li></ul><ul><li>QFT positive </li></ul><ul><li>CXR negative </li></ul>Viriya Lekprasert,obgyn,18745
  39. 39. Suspicion, but ppd. Neg. <ul><li>Th. Female , 23 yr. </li></ul><ul><li>Recurrent PID </li></ul><ul><li>Ppd test negative </li></ul><ul><li>QFT negative </li></ul>Viriya Lekprasert,obgyn,18745
  40. 40. FINALE <ul><li>Unexplained : infertility, abnormal menstruation, pelvic pain, pelvic infection </li></ul><ul><li>High suspicion clinical FGTB </li></ul><ul><li>Tuberculin test, QuantiFERON-TB </li></ul><ul><li>Other investigation </li></ul><ul><li>“ Have problem ! ? , </li></ul><ul><li>consult Internal Medicine ” </li></ul>Viriya Lekprasert,obgyn,18745

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