TUBERCULOSIS OF FEMALE GENITAL TRACT

Dr m.Indira mbbs dgo

Jr

IRT PMCH1

INTRODUCTION

One third of world population infectedLife time risk of TB following infection

~5-10%Global emergency

10 million new cases per year 3 million deaths every year

India 14 million people 5-16% cases of infertility

Drug resistant TBHIV co-infection

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M TUBERCULOSIS

Aerobic bacillus

Non-spore forming

Non-motile

Generation time: 12-20 hours

Culture 3-6 weeks 1-2 weeks 3

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SOURCE OF INFECTION

Always secondary. Primary focus- lungs, lymph node, urinary

tract, bones and joint. Long latent period -10- 15 years . Menarche- increased chance of genital

tuberculosis.

MODE OF SPREAD

Blood spread most common -90%. Direct spread from peritonium- bowel lesion

lymphatics from mesentric nodes- 7%. Sexually transmitted- 1%.

PATHOLOGY

Fallopian tube 90% Uterus 60% Ovaries 30 % Cervix 1-2 % Vulva and vagina 1%

FALLOPIAN TUBE TUBERCULOSIS

By blood spreadMostly bilateral Tuberculous endosalphingitisSubmucosal layer of ampullary part

Wall thickened enlarged tortous Initially fimbrial end openCaseation in the wall of the tube pyosapinx

FALLOPIAN TUBE

Tuberculous exosalphingitis Direct extension Peritoneal surface studded with miliary

tubercles Tobacco pouch appearance-dilated distal

end.

PATHOLOGY

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FROZEN PELVISTOBACCO POUCH

APPEARENCE

UTERUS

70% Spread from tube Cornual end Tubercle situated basal layer Ashermans syndrome -Endometrial ulceration

adhesion Pyometra- caseation material collects

OVARIES

Tubercles on the surface Adhesion Thickening of capsule Caseating abcess

CERVIX

5-10% Descending infection Intermenstrual bleeding or post coital

bleeding Ulcer or red papillary erosion DD ca cervix Biopsy

VULVA&VAGINA

Rare Shallow painful ulcer undermined edge Hypertrophic Diagnosis by histology

CLINICAL FEATURES

Asymptomatic 10 Infertility 35-65 Menstrual abnormalities Menorrhagia Amenorrhoea Pain, dysmenorrhoea Tender fixed adnexal mass,abdominal mass Repeated PID Vaginal discharge Post coital bleeding

HYSTEROSALPINGOGRAM FINDINGS

Suspected genital TB avoid HSG Rigid non peristaltic pipe like tube. Beaded appearance ,calcification of tube Bilateral cornual block Jagged fluffiness of tubal outline Vascular lymphatic extravasation. Tobacco pouch appearance.

HYSTEROSALPINGOGRAM VIEW

16Figure : 28-year-old woman with genital tuberculosis. Hysterosalpingogram shows bilateral tubes convoluted and fixed. There is a loculated spill (small

arrows) on the right side suggestive of adhesions.

RADIOGRAPHIC VIEW

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Fig. 6. Radiograph demonstrates lymphatic extravasation, a deformed uterine cavity, and a narrow-rigid fallopian tube with a dilated and closed fimbrial end on the right side.

Fig. 8. The entire fallopian tube appears rigid and exhibits small terminal sacculations.

DIAGNOSIS OF GENITAL TB

Mantoux ,ESR. Dilatation and curettage Cornual end Premenstrual HPE , BACTEC culture, PCR Diagnostic laparoscopy Biopsy X-RAY chest ,sputum AFB HIV ELISA

MANTOUX 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 tuberculosissensitivity - 55% specificity - 80%

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MICROSCOPIC APPEARANCE OF TUBERCULAR LESION

Typical granuloma formed by lymphocytes,multinucleated giant cells,epitheloid cells, Surrounding central area of caseation.

TUBERCULOUS SALPINGITIS.

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Fig.. Tuberculous salpingitis. Chronic salpingitis due to tuberculosis presents the characteristic histologic features of the tuberculous granuloma: lymphocytes, epithelioid cell granulomata, and giant cells of both the Langerhans and the foreign body type are seen. Tuberculous infection of the fallopian tube often results in an “adenomatous” proliferation of the lining epithelium. This is seen on the left of this photomicrograph and may give rise to confusion with adenocarcinoma. (×100.)

Fig Tuberculous salpingitis may contain Schaumann bodies, which are more characteristic of sarcoidosis than tuberculosis. These are conchoidal, laminated, calcified structures, usually surrounded by foreign body giant cells. (×100.).

TUBERCULOUS ENDOMETRITIS

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Fig. 4. Tuberculous endometritis. Photomicrograph of a single tuberculous granuloma is seen on the left, consisting of central epithelioid cells, with a Langerhans-type giant cell surrounded by a cuff of lymphocytes. No central caseation is present. The surrounding endometrium appears completely normal; the glands are proliferative, and there is no infiltrate in the stroma, seen on the right. (×100.)

DIFFERENTIAL DIAGNOSIS

Ovarian cyst Pelvic inflammatory disease Ectopic pregnancy Carcinoma cervix Elephantiasis vulva Pregnancy

TREATMENT OF GENITAL TB

CHEMOTHERAPY WITH ATT

INITIAL PHASE 2 MONTHS Isoniazid 5mg/kg Rifampicin 10mg/kg Pyrazinamide 25mg/kg Ethambutal 15mg/kg

CONTINUATION PHASE 4 MONTHS Rifampicin and INH biweekly Resistant cases with HIV -1 year

TREATMENT OF GENITAL TB

Patient considered cured if 2 histological and bacteriological reports are negative.

DRUGS USED IN RESISTANT CASES Capreomycin Kanamycin Ethionamide Para-amino salicylic acid cycloserine

SURGICAL TREATMENT

INDICATIONS Progression of disease Persistent active lesion Pyosalpinx Pyometra Persistence of symptoms Persistence of fistula Surgery followed by full course

chemotherapy.

SURGICAL TREATMENT

Totalhysterectomy with bilateral salpingo oopherectomy

Vulvectomy.

TUBOPLASTY IS CONTRAINDICATED Reactivation Fertility cannot be restored ART- IVF

PROGNOSIS

CURE RATE 90% FERTILITY 10% TUBAL PREGNANCY VERY HIGH ABORTION ALSO OCCUR ONLY 2 PERCENT HAVE LIVE BIRTHS

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