cases report female genital tuberculosis in thai

1. 1
Female genital tuberculosis : Clinical approach and clinical management
Viriya Lekprasert
Department of Obstetric and Gynecology , Vichaiyut Hospital , Bangkok , Thailand
Abstract
In this review, female genital tuberculosis was diagnosed by history and clinical
finding combined with positive PPD test in six cases during four years ( January 2003 to
January 2007 ). Actually , there were eight cases which positive PPD test , but two cases were
not compliant to anti-tuberculosis treatment . Thus these two cases were not reported in this
literature . Five of eight cases presented with recurrent infection , one case presented with
pelvic pain , one case presented with amenorrhrea and one case presented with infertility .
Introduction
Tuberculosis ( TB) is the health problem in developing countries. The most common
site TB in human is pulmonary ( 80% ) (). Extra - pulmonary sites which can get infected
(20%) are renal, bone, central nervous system and genital organ.
In female genital organ, the most common site for TB infection is a fallopian tube
( 50% - 100% ) (6). The uterus and ovaries can be infected about 50 % and 20 % respectively
(6)
. The incidence of female genital TB ( FGTB ) is varied among different countries. In 1980
Swedish Hospital report 0.02% - 0.05% (3). In 2002 Department of Obstetric and Gynecology
University Malaya Medical Center, Malaysia reported 0.03% (4). But in 2003, Department of
Obstetric and Gynecology Maulana Azad Medical College, India reported 0.75% - 1% (5).
Female genital tuberculosis ( FGTB ) can be difficult to diagnose, because it is often
a disease with absent or few symptoms. The disease may not become manifested for more
than 10 years after initial seeding in the genital tract, because it is an indolent infection (). The
most common presentation reported were infertility (44%), pelvic pain (25%), vaginal
bleeding (18%), amenorrhea ( 5%), vaginal discharge ( 4%) and postmenopausal bleeding
( 2%). Less common presentation included abdominal mass, ascites, tubo-ovarian abcess, and
vague abdominal distension, These symptoms tend to be late features (7) .
From January 2003 to January 2007 , there were 8 cases which had clinical of FGTB
with PPD test positive in my 12,497 cases of gynecological patients ( 0.06 % ). Six cases
accepted to complete anti - tuberculosis treatment ( ATT ) and all of them had remission of
their symptoms. Two cases who are not compliant to ATT, and now they still have their
symptom amenorrhea and infertility.
Case report 1
A 33 year-old, gravida 1 para 0 abortion 1 Thai woman presented with multiple
episodes of recurrent pelvic inflammatory disease (PID) every 1-2 months for over six
months. And she complained about constitutional symptoms, weight loss, lethargy and
dyspnea. The last episode of PID was not improved by the same antibiotic regimen. Physical
examination revealed two enlarged cervical lymph nodes at both sides of mandibular area,
diameter 2.5 cm., no tenderness was found. Pelvic examination revealed triad of PID and
enlarged right groin node of 2.5 cm. in diameter with tenderness, enlarged left groin nodes in
chain, each of 0.5-1 cm.in diameter.
Vagina swab wet smear had numerous white blood cells and pseudohyphae. Cervical
swab culture had numerous streptococcus viridans, and moderate candida albicans.
Complete blood count, ESR, C-reactive protein were normal. Chest x-ray and transvaginal
ultrasound were normal. PPD-test was done due to recurrence of PID and the result was

2. 2
positive which diameter of induration over 1.5 cm. So FGTB was diagnosed by history and
clinical judgment.
A 3-months regimen of isoniazid + pyridoxine, rifampicin, pyrazinamide and
ethambuthol was administered, followed by 5-months of isoniazid + pyridoxine, rifampicin
and ethambuthol. The PID symptoms were resolved with this treatment. One year later she
had only vaginitis about 2-3 episodes per year and she has no further constitutional symptom
again.
Case report 2
A 36 year-old, gravida 1 para 0 abortion 1 Thai woman presented with multiple
episodes of recurrent bartholinitis and abscess every 3-5 months for over two years. She
contacted a pulmonary TB patient eight years ago, who stayed in the same house for one year.
She did the first PPD test in 1997, the result was negative. The second PPD test in 2004, also
revealed a negative test.
The last episode of bartholin abscess was on 11 November 2005 and PPD test was
done again, the result was positive which diameter of induration over 1 cm. Chest x-ray was
normal. So FGTB was diagnosed by history and clincal judgment. Marsupialization was
done for the treatment of bartholin abscess.
A 3-months regimen of isoniazid + pyriodoxine, rifampicin, pyrazinamide and
ethambuthol was administered, followed by 5-months of isoniazid + pyridoxine, rifampicin
and ethambuthol. After a complete course of anti - tuberculosis treatment , the patient
requested a repeat PPD-test . The result was negative.
During eight months of an antituberculosis treatment, bartholinitis or abscess was
disappeared. Till present , she has been healthy.
Case report 3
A 26 year-old, gravida 0 para 0 abortion 0 Thai woman presented with chronic pelvic
pain for one year. The first episode of pelvic pain was from leakaged corpus luteal cyst. The
patient was treated by supportive and symptomatic treatments. A combined oral
contraceptive pill was used to prevent the recurrence. The following month she felt midcycle
pain again. This episode she had constitutional symptoms : spot bleeding , lethargy and
dizziness with postural syncope. After this episode she had dysmenorrhea every month.
Patient was adviced DMPA for therapeutic treatment of endometriosis but she was not
compliant to the treatment.
Nine months later she presented with pelvic pain. Constitutional symptoms were
lethargy dizziness and weight loss. PPD test was done due to chronic pelvic pain, the result
was positive (diameter of induration was 2.5 cm., which was seroconversion from last year).
Chest x-ray was normal. Anti - tuberculosis treatment was started with DMPA for female
genital tuberculosis with pelvic endometriosis respectively.
A 3-month regimen of isoniazid + pyridoxine, rifampicin, pyrazinamide and
ethambuthol was administered. The patient had blurr vision after 3-month regimen, so
ethambuthol was stopped. Then anti - tuberculosis treatment was changed to partial course of
Dutt and Stead regimen consisting of isoniazid 900 mg. per day ( plus pyridoxine ) and
rifampicin 600 mg. per day twice weekly for five months. Blurred vision symptom was
relieved after ethambuthol was discontinued.
After treatment of female genital tuberculosis and pelvic endometriosis, frequency
and severity of pelvic pain was reduced.

3. 3
Case report 4
A 21 year-old gravida 1 para 0 abortion 1 Thai woman presented with genital ulcer
and dysuria. She had a history of recurrence PID every 1-2 months for over six months. She
has a risk of sexual transmitted disease ( STD ) due to the history of sharing a sexual partner
for many years. And she is at risk of TB because she contacted with her friend who had
history of pulmonary TB which complete treatment.
Pelvic examination revealed group of vesicles on vulvar. She felt a burning pain in
this area. PPD test was done due to history of recurrent PID and contacted TB. The result
was positive ( diameter of induration was 1.5 cm..) Chest x-ray was normal. So FGTB with
herpes simplex genitalis was diagnosed by history and clinical judgement. Herpes simplex
genitalis was treated with both topical and oral forms of acyclovir .
A 3-months regimen of isoniazid + pyriodoxine, rifampicin, pyrazinamide and
ethambuthol was administered, followed by 5-months of isoniazid + pyridoxine, rifampicin
and ethambuthol. After 3 months of treatment she had condyloma acuminata. Electric cautery
was used to destroy lesion of condyloma. After a complete ATT she had only one episode of
vaginitis.
Case report 5
A 22 year-old gravida 0 para 0 abortion 0 Thai woman presented with chronic
vaginitis every 2-3 months. She has a risk of STD due to the history of sharing a sexual
partner for many years . And she had pulmonary TB two years ago with a complete
treatment. The result of PPD test was positive ( diameter of induration was 1.5 cm. ). Chest x-
ray showed minimal fibronodular infiltration seen in both upper lungfield and linear
atelectasis of the right base. So FGTB was diagnosed by history and clinical judgement.
A 3-months regimen of isoniazid + pyriodoxine, rifampicin, pyrazinamide and
ethambuthol was administered . Then she had PID and admitted for intravenous antibiotics.
After a complete course of ATT which followed by 5-months of isoniazid + pyridoxine,
rifampicin and ethambuthol she had only a single episode of vaginitis .
Case report 6
A 26 year-old gravida 1 para 0 abortion 1 Thai woman presented with yellowish
greenish discharge from her vagina. She had multiple episodes recurrence of PID for two
years
Pelvic examination revealed fish odor smell homogeneous discharge . Vaginal swab
wet smear had clue cells . PPD- test was done due to history of recurrence of PID . The result
was positive ( induration 2.5 cm. ) . Chest x-ray was normal. So FGTB with bacterial
vaginosis was diagnosed from history and clinical judgement.
Bacterial vaginosis was treated by clindamycin 900 mg. oral form for seven days .
ATT by Dutt and Stead regimen for FGTB consisting of INH 300 mg. per oral four times per
day and rifampicin 600 mg. per oral four times per day for one month , followed by INH 900
mg. per oral and rifampicin 600 mg. per oral twice weekly for another eight months . The
patient responded well to this regimen .

4. 4
Discussion
Female genital tuberculosis often manifests in discrete forms and diagnosis may be
missed if not considered in differential diagnosis (3) . In this series, every case had chief
complaint liked other cases in gynecological clinic but they had history of recurrenced . So it
would have underlying cause, which related to these recurrence. Extrapulmonary TB can get
infected in 20% () , because it is indolent infection, it may not become manifested more than
10 years after initial seeding in the genital tract () .
PPD test was done to find TB infection in this series. PPD test has sensitivity 55%,
specificity 80% () in FGTB. Chest x-ray was done to exclude pulmonary TB. Saracoglu and
colleagues found that more than 75% of patients of FGTB had a normal chest x-ray () . On
hysterosalpingogram of FGTB may found coronal block, fimbrial block, beaded tube,
hydrosalpinx and/or filling defects in the uterine cavity about 70% () .
Every cases in this series had positive PPD-test. There were five cases had negative
study of chest x-ray and one case had fibronodular infiltration (this patient was pulmonary TB
two years ago). Hysterosalpingogram was not done due to patients were not compliance.
The diagnosis of FGTB is confirmed by histologic examination, which reveals typical
granuloma and/or positive acid-fast stain and culture of endometrial biopsy tissue. Menstrual
fluid has been reported to be culture positive more often than biopsy specimens.
Hysteroscopy and selective sampling may enhance diagnosis yield () . The typical lesions of
FGTB are epitheloid cell granulomas with or without Langerhans giant cells. Caseation
necrosis is rare and tends to be a late feature () . Polymerase chain reaction (PCR) can be used
for diagnosis of FGTB. Samples from endometrium aspirates (EA), Endometrium biopsies
(EB) and fluid from Douglas pouch (FDP) were investigated for mtP 64 gene of
mycobacterium tuberculosis by PCR. Bhanu V. founded the presence of M. tuberculosis
DNA was observed in EB 53.3%, EA 47.6% and FDP 16%. ()
The most common site of FGTB infection in one series was the fallopian tube, which
was affected in almost all patients the endometrium was 50%, ovary was 20% and cervix was
1% () . So, if pathology is in fallopian tube even we do sampling in endometrium we cannot
confirm by histology. After counseling about percentage of histologic finding to patient in
this series, all patients decided not to do invasive diagnosis. When critical thinking from
history , physical examination and positive PPD test , FGTB was diagnosed and started anti-
tuberculosis treatment.
In this series PPD test is the sufficient tool for diagnosis FGTB. Every patients had
recurrent gynecological symptom and someone could not remissioned by standard regimen
treatment. TB is the health problem and prevalence in developing countries. Female genital
organ is the third most common site of extrapulmonary TB from lymph nodes and pleura () .
So, FGTB is keeped in mind in this series, eventhough we do hysterosalpingogram,
endometrium biopsy or hysteroscopy if its show negative, I still consider diagnosis of FGTB.
Because we should treat patients to remission from their problem. If we delay in diagnosis
and treatment , FGTB may progress to late features ( ) .
There is no standard anti - tuberculosis treatment protocols for FGTB ( ). ATT
regimen in this series was modified from “standardized re-treatment regimen”. () Consisting
of isoniazid + pyridoxine, rifampicin, pyrazinamide and ethambuthol were administered for
three months. Followed by five months of isoniazid + pyridoxine, rifampicin and
ethambuthol. Patients were responded well by remission from their symptom and decreased
in frequency of recurrence.
There was one patient had side effect from ethambuthol. She was blurr vision after
three months regimen. So, ATT was changed to partial course of “Dutt and Stead” () regimen
for five months. Blurr vision disappeared after ethambuthol was stopped.

5. 5
There was one case used Dutt and Stead regimen (which has successful rate 95%).
This regimen is consisted of INH 300 mg. per oral four times per day and rifampicin 600 mg.
per oral four times per day for one month. Followed by INH 900 mg. per oral and rifampicin
600 mg. per oral twice weekly for another eight months. (10) The patient was responded well
to this regimen.
References
1. Raviglione MC, O’Brien RJ ; Tuberculosis; In: Eugene B.W.; ET Harrison’s Manual of
Medicine: 15th ED.; India: Mc Graw-Hill; 2002,451-460.
2. Dawn C.S.; Pelvic infecions; In: Dawn C.S.; ed Texbook of Gynaecology and
Contraception: 9th ed.; Calcutta:Arati Dawn; 1998,321.
3. Teresa W.P. Chow, Boon KL, Sivanesaratnum V. The masquerades of female pelvic
tuberculosis: Case reports and review of literature on clinical presentations and diagnosis.
J. Obstet. Gynaecol. Res. 2002;28(4):203-210.
4. Sivanesaratnam V, Lim BH, Sivanesan S, Menon A. Pelvic tuberculosis: an uncommon
gynaecological problem in Malaysia. J Trop Med Hygiene 1986;89:167-169.
5. Arora VK, Gupta R, Arora R. Female genital tuberculosis. Ind. J. Tub. 2003;50(9):9-10.
6. Tuomala RE, Chen KT; Gynecologic infection; In:Kenneth J.K; ET Kistner’s
gynecology: 7th ED.; Missouri: Mosby;1999, 462.
7. Hassoon A. Female genital tuberculosis: uncommon presentation of tuberculosis in the
United States. The American Journal of Medicine. 2005;118:1295-1299.
8. Saracoglu of Mungan TF, Tanzer F. Pelvic tuberculosis. Int. J. Gynecol. Obstet.
1992;37:115-120.
9. Sin SY, Lawrence CH. Female genital tuberculosis: An update. Hong Kong Practitioner.
1996;17(1):18-26.
10. Stead W. Genital tuberculosis. Longwood Combined Infectious Disease Conference
2001; 1-8.
11. Bhanu NV, Singh UB, Chakraborty M. Improved diagnostic value of PCR in the
diagnosis of female genital tuberculosis leading to infertility. J Med Microbiol.
2005;54:927-31.

6. 6