The Background Of Tuberculosis

Published Date: 02 Nov 2017

ABSTRACT

Tuberculosis(TB) is a major health problem in developing countries including India and genital tuberculosis(GTB) is responsible for infertility in a significant proportion of these women. Inspite of recent advances in medicine and availability of sophisticated investigative modalities, definitive diagnosis of GTB is elusive in absence of high clinical suspicion. Majority of women with genital tuberculosis present with infertility. Oligomenorrhea or amenorrhea is more common with other vague symptoms. Laparoscopy is now a well recognized procedure in the diagnostic work up of patients with infertility. In a clinically suspicious case, endometrial biopsy(EB) should be followed by laparoscopy. The treatment of GTB should begin with anti tuberculous therapy. Pregnancy rates can now be significantly improved with In vitro fertilization(IVF). The fact remains that fertility rates are not optimistic in genital TB patients even after treatment.

INTRODUCTION

Tuberculosis(TB) is a major health problem in developing countries including India and genital tuberculosis(GTB) is responsible for infertility in a significant proportion of these women 1 .It is difficult to assess the actual incidence of genital tuberculosis accurately, as the disease is discovered incidentally in many patients and majority of them are asymptomatic 2. It is estimated that 5-10% of infertile women worldwide have GTB, although this varies from less than 1% in the United States to nearly 18% in India 2. When TB affects genital organs of young females, it produces devastating effects by causing irreversible damage to the fallopian tube resulting in infertility which is difficult to cure both by medical and surgical methods 3, 4

CASE REPORT

A 28 year old female, a case of primary infertility for 8 years, with irregular cycles, 2/15-20 days with scanty flow came to our gynaecology out patient department. On history, there were no symptoms suggestive of any chronic systemic diseases related to infertility.

No significant family history. She gave a history of multiple gyanecological evaluation for infertility over the past 7 years. Semen analysis was normal. Hormonal assay done one year back was normal ( Thyroid function test, Serum prolactin, Serum FSH, LH, Serum Estriol, progesterone etc) USG showed uterus didelphus with an hypoechoic cyst with internal echoes measures 8.2x8x9.2 cm seen in the adnexa ( site could not be identified due large size of the cyst) left adnexa appears normal. MRI done outside showed a hypoplastic uterus with bicornuate unicollis type of mullerian duct anomaly with endometriotic change in left uterine horn with small collection ,both the ovaries appears unremarkable, HSG showed uterus of bicornuate, probably unicollis variety, irregularities, crenations are noted to the uterine horn silhouettes - probable endometritis

Both the tubes are visualised almost throughout their extents, no peritoneal spillage of contrast is visualized. Soft tissue circumscribed calcifications are noted across left hemipelvis-?adnexal. Repeat USG at our centre showed no evidence of adnexal cyst but identified multiple calcifications in the pelvis. Hb : 9.5 gm%, TLC : 6800/cu.mm, DLC : n48% lymphocytes 34% e 18% ,Urine R/M : gross : pyuria + , albumin - +++, pus cells- plenty/hpf, Urine culture : No growth, negative for AFB.RBS :115 mgs%, HIV status negative, XRay Chest showed a nodular oval well circumscribed opacity in left upper zone ?hamartoma ? tubercular lesion.

On examination, patient was thin built & ill nourished PR: 76 bpm BP: 100/70 mm/hg. On abdominal examination, soft, no tenderness, no organomegaly. On vaginal examination , cervix was normal, uterus atrophic, fornices free, no mass palpable, no tenderness.

Patient posted for diagnostic laparoscopy . Intraoperative findings :large bowel loops , omentum, peritoneal surface studded with tubercles, ? miliary abdominal tuberculosis. No evidence of ascites. One horn of uterus visualised, atrophic and adherent to anterior abdominal wall. Parietal peritoneum & omental biopsy collected.

Subsequently omental , peritoneal biopsy report suggestive of Tuberculosis. Patient was started on anti koch’s treatment( AKT) and discharged. She is on regular follow up. There is an improvement in the physical well being of the patient. Fertility potential is yet to be evaluated after completion of AKT.

DISCUSSION

Genital tuberculosis continues to be a major cause for female infertility in developing countries including India. Inspite of recent advances in medicine and availability of sophisticated investigative modalities, definitive diagnosis of GTB is elusive in absence of high clinical suspicion.

The most common initial symptom of genital tuberculosis is infertility with a reported incidence of 40 – 80%.Chronic lower abdominal pain or pelvic pain is the second most common symptom seen in 20-50% of patients.Menstrual pattern may be disturbed in 10-60% of patients. The change may be towards menorrhagia or metrorrhagia as in other pelvic infections but oligomenorrhea or amenorrhea is more common.Abnormal vaginal discharge is not significant in endometrial TB5

Haematological examination shows tendency towards lymphocytosis. Chest X-ray may show a picture of active or healed lesion. Microscopic haematuria, abacteriuric pyuria may suggest urinary tract involvement. Mantoux has limited utility in diagnosing active genital TB during child bearing age. However, in infertile women with a positive mantoux test , laparoscopy should be advocated early.Endometrial biopsy(EB) for TB remains the most commonly used procedure. It detects 50-60% of patients with genital TB. A negative EB does not rule out pelvic involvement5. Due to the paucibacillary nature of GTB, diagnosis by mycobacterial culture and histopathological examination (HPE) have limitations and low detection rate6. HSG is unreliable as a diagnostic tool & can cause exacerbation of the disease.Laparoscopy is now a well recognized procedure in the diagnostic work up of patients with infertility. In a clinically suspicious case, EB should be followed by laparoscopy5

In our case, the diagnosis of bicornuate uterus had possibly mislead the investigation, such that it had been focussed upon as the main cause for her infertility and thereby the real diagnosis of tuberculosis was neglected. Women with bicornuate uterus can expect a reasonable success in delivering a living child (60%).There is no evidence of primary infertility in bicornuate uterus7

The treatment of GTB should begin with anti tuberculous therapy. Historically pregnancy outcomes after treatment have been generally poor and the risks of ectopic pregnancy and spontaneous abortion are increased. Pregnancy rates can now be significantly improved with In vitro fertilization(IVF)(16% - 25% per transfer) but success remains dependent on normal endometrial function. Success rate is high with trophic endometrium and reduces to nil in cases of atrophic endometrium. An initial investigation of endometrium given the high rate of uterine extension is warranted prior to initiating IVF in patients with GTB8.

TB PCR test, considered as a gold standard for assessment of endoscopic features, is not 100% sensitive and specific. Like any other bacteriological test available for diagnosing TB, it is known to give a small number of false-positive and -negative results .

For the endoscopic features which are considered suggestive of TB, there are no defined criteria in literature. However, in a study conducted by Sharma JB et al, the findings on laparoscopy suggestive of tuberculosis were tubercles on peritoneum (12.9%) or ovary (1.2%), tubovarian masses (7.1%), caseous nodules (5.8%), encysted ascitis in 7.1% women. Various grades of pelvic adhesions were seen in 65.8% of women. The various findings on fallopian tubes were normal looking tubes in 7.1%, inability to visualize in 14.1%, presence of tubercles on tubes in 3.52%, caseous granuloma in 3.52%, hydrosalpinx in17.6% ,pyosalphinx, beaded tube with tobacco pouch appearance in 2.35% women.One of the two tubes was patent in 23.3% cases , while they were either not seen or blocked at various sites with cornual end being most common10.

This case report could prove to be an eye opener for gynaecology practitioners dealing with infertility patients in our country. Tuberculosis, in the past was considered as a leading diagnosis in cases of unexplained infertility in developing countries. In the present era, with the introduction of DOTS , we seem to be coming across fewer patients with GTB as a cause for infertility. However, even in the present scenario, in our country, there may be many such cases of GTB wandering from pillar to post for want of appropriate diagnosis and treatment.

CONCLUSION

We have made an attempt to report this case to re emphasize the existence and high incidence of genital TB in our country .This may just be the tip of the iceberg…The gynaec infertility specialists should keep tuberculosis in mind while evaluating infertility. The diagnosis of genital TB remains an enigma. Early Diagnostic laparoscopy may be the only efficient tool to aid the evaluation.

CONSENT

Consent for publication of this case report was taken from the patient, copy of which is available with the corresponding author.

ACKNOWLEDGEMENT

We would like to extend our heartfelt gratitude to the heads of Dept, Obstetrics & Gynecology and Pathology.