Endometrial tuberculosis among patients undergoing endometrial biopsy at Tikur Anbesa specialized hospital, Addis Ababa, Ethiopia

An evaluation of Composite Reference Standard (CRS) for diagnosis of Female Genital Tuberculosis

BACKGROUND

Female genital tuberculosis (FGTB) is a common cause of infertility in developing countries. Its diagnosis is difficult due to its paucibacillary nature, with no single test having high sensitivity and specificity. This study is to share the experience of using Composite Reference Standard (CRS) for the diagnosis of FGTB.

METHODS

This is a prospective study conducted between September 2017 to June 2019, over 100 infertile females found to have FGTB on composite reference standard which consisted of acid-fast bacilli on microscopy or culture, histopathological evidence of epithelioid granuloma, positive gene Xpert on endometrial sample or definite or probable finding of FGTB on laparoscopy.

RESULTS

A total of 100 infertile women (78% primary, 22% secondary) found to have FGTB on CRS were enrolled in this study. Mean age, body mass index, parity and duration of infertility were 28.2 years, 23.17 kg/m², 0.24 ± 0.12 and 2.41 years respectively. Various symptoms were scanty menses (16%), irregular cycle (7%), dysmenorrhea (11%), pelvic pain (11%). Various signs were vaginal discharge (65%), adnexal mass (6%), tubo-ovarian mass on ultrasound (15%), abnormal hysterosalpingography findings (57.14%), positive polymerase chain reaction test (65%) and abnormal hysteroscopy (82.2%). The positive findings on CRS were positive AFB on microscopy or culture (3%), positive gene Xpert (28%) (done in some cases), epithelioid granuloma on histopathology (13%), definite findings on laparoscopy like tubercles, caseous nodules and beaded tubes in (57.19%) patients while probable findings of FGTB like straw colored fluid in POD, extensive dense pelvic, peri-tubal, peri-ovarian adhesions; hydrosalpinx; tubo-ovarian mass; thick fibrosed tubes; mid tubal block; peri hepatic adhesions (Fitz Hugh Curtis Syndrome); hyperemia of tubes/blue uterus on chromotubation were seen in (48.8%) patients. All patients found to be positive on CRS were given 6 months of anti-tubercular therapy.

CONCLUSION

This study demonstrates the high reliability of use of composite reference standard for diagnosis of FGTB.

Comparison of Polymerase Chain Reaction (PCR), Microbiological and Histopathological Observations in the Diagnosis of Endometrial Tuberculosis

BACKGROUND

Female genital tuberculosis often faces diagnostic challenges due to the asymptomatic nature of the disease. Our study aims at comparing the microbiological and histopathological results with PCR in diagnosing genital tuberculosis in endometrial curettage specimens.

METHODS

Around 139 patients with diverse gynaecological complaints were recruited for the study, and endometrial curettage specimens were collected. The specimens were subjected to microbiological culture and staining, histopathological examination and PCR to look for the presence of M. tuberculosis. Statistical analyses of the PCR results include calculating sensitivity, specificity, positive and negative prediction values and positive and negative likelihood ratios.

RESULTS

PCR yielded a detection rate of 41.7% (58/139) when compared to the microbiology (2.15%) and histopathology results (1.43%). PCR with hsp65 and cfp10, in combination, detected 20% of the cases. Statistical analyses were suggestive that PCR with hsp65 showed a higher sensitivity and specificity of 50% and 92.59% respectively.

CONCLUSION

The results obtained in this study suggest that for a definitive diagnosis, combinations of the results from various diagnostics techniques can only be considered.

Female genital tuberculosis: Revisited

Female genital tuberculosis (FGTB) is caused by Mycobacterium tuberculosis (rarely Mycobacterium bovis and/or atypical mycobacteria) being usually secondary to TB of the lungs or other organs with infection reaching through haematogenous, lymphatic route or direct spread from abdominal TB. In FGTB, fallopian tubes are affected in 90 per cent women, whereas uterine endometrium is affected in 70 per cent and ovaries in about 25 per cent women. It causes menstrual dysfunction and infertility through the damage of genital organs. Some cases may be asymptomatic. Diagnosis is often made from proper history taking, meticulous clinical examination and judicious use of investigations, especially endometrial aspirate (or biopsy) and endoscopy. Treatment is through multi-drug antitubercular treatment for adequate time period (rifampicin, isoniazid, pyrazinamide, ethambutol daily for 60 days followed by rifampicin, isoniazid, ethambutol daily for 120 days). Treatment is given for 18-24 months using the second-line drugs for drug-resistant (DR) cases. With the advent of increased access to rapid diagnostics and newer drugs, the management protocol is moving towards achieving universal drug sensitivity testing and treatment with injection-free regimens containing newer drugs, especially for new and previously treated DR cases.