Female genital tuberculosis

Imaging of infra-thoracic tuberculosis

Tuberculosis (TB) is a potentially curable disease that is a leading cause of death globally. While it typically affects the lungs, this disease may involve many extra-pulmonary sites, particularly in patients with risk factors. Extra-pulmonary TB often mimics a variety of different diseases, posing a diagnostic dilemma. Imaging aids in early diagnosis of TB, especially in patients with non-specific or atypical symptoms found at extra-pulmonary infra-thoracic locations. Imaging also helps guide appropriate laboratory investigation, monitor disease progress, and response to treatment. This review aims to highlight the imaging spectrum of TB affecting the infra-thoracic region, that is, gastrointestinal tract, abdominal lymph nodes, peritoneal cavity, intra-abdominal solid organs, and urogenital system.

Primary Extrapulmonary Rifampicin Mono-Resistant Tuberculosis (TB) of the Endometrium in a Sexually Inactive 20-Year-Old Indian Female: A Very Rare Case

Female genital tract tuberculosis (TB) is less frequently reported, even in endemic countries. Often, the diagnosis is incidental and is seen with the involvement of pulmonary or extrapulmonary sites. Isolated female genital tract TB is quite rare, and cases of primary extrapulmonary rifampicin mono-resistant TB of the genital tract are rarest of the rare. In this case, a 20-year-old sexually inactive female with no history of TB presented with complaints of pain in her abdomen for past two months and absence of menstrual cycles since two years and was later diagnosed based on hysteroscopy, endometrial biopsy, and cartridge-based nucleic acid amplification test (CBNAAT) with primary extrapulmonary rifampicin mono-resistant TB of the endometrium. She was started on a WHO-recommended rifampicin mono-resistant TB regimen for 24 months but was ultimately lost to follow-up.

Poor in vitro fertilisation outcomes in genital tuberculosis – Case report

Introduction and importance

Genital tuberculosis (TB) exerts significant damage in the reproductive organs, particularly the Fallopian tubes and endometrium. Infertility is one of the most common presenting causes, often subsequently requiring assisted reproductive technology (ART). However, we have not had many experiences with genital TB despite being a country endemic for TB. This case series highlights the challenges we face and the solutions we wish we had.

Case presentation

In this case series, we recruited 7 patients undergoing in vitro fertilisation (IVF) treatment previously diagnosed with TB between January 01, 2014 and June 30, 2021. Patients were recruited at the beginning of their IVF treatments. Of 7 patients, 2 patients (28.6%) achieved live birth. 5 patients (71.4%) failed to conceive. All patients had good and/or excellent quality embryos upon transfer but only 2/7 managed to conceive and delivered.

Clinical discussion

Genital TB is often silent and only encountered during workup for infertility. Genital TB often produces extensive damage on the linings of the endometrium and Fallopian tubes, accounting for the recurrent implantation failures associated with the disease. Whilst antitubercular treatment may improve the prognosis, many women still fail to conceive.

Conclusion

Genital tuberculosis remains a significant issue in infertility. Cases are often silent and management is often delayed. IVF is often required due to the longstanding damage caused beforehand yet prognosis may remain poor.

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Genital tuberculosis is a significant yet underdiagnosed etiology of infertility.

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Its profound severity often requires in vitro fertilisation for conception.

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Poor prognosis may still be found despite IVF due to recurrent implantation failures.

Etiopathogenesis, Challenges and Remedies Associated With Female Genital Tuberculosis: Potential Role of Nuclear Receptors

Extra-pulmonary tuberculosis (EPTB) is recognized mainly as a secondary manifestation of a primary tuberculosis (TB) infection in the lungs contributing to a high incidence of morbidity and mortality. The TB bacilli upon reactivation maneuver from the primary site disseminating to other organs. Diagnosis and treatment of EPTB remains challenging due to the abstruse positioning of the infected organs and the associated invasiveness of sample acquisition as well as misdiagnosis, associated comorbidities, and the inadequacy of biomarkers. Female genital tuberculosis (FGTB) represents the most perilous form of EPTB leading to poor uterine receptivity (UR), recurrent implantation failure and infertility in females. Although the number of TB cases is reducing, FGTB cases are not getting enough attention because of a lack of clinical awareness, nonspecific symptoms, and inappropriate diagnostic measures. This review provides an overview for EPTB, particularly FGTB diagnostics and treatment challenges. We emphasize the need for new therapeutics and highlight the need for the exaction of biomarkers as a point of care diagnostic. Nuclear receptors have reported role in maintaining UR, immune modulation, and TB modulation; therefore, we postulate their role as a therapeutic drug target and biomarker that should be explored in FGTB.

Role of microbiological tests in diagnosis of genital tuberculosis of women with infertility: A view

OBJECTIVE

India is a country sharing one fourth of the global incidence of tuberculosis. It is much easier to diagnose pulmonary cases, but challenges are with extrapulmonary cases. Genital tuberculosis is considered as an important cause of infertility in young females in India and difficult to diagnose. It requires incorporation of different modalities that should correctly, timely and rapidly diagnose the case.

METHODS

This study was conducted retrospectively for a period of 12 months on 438 endometrial samples from females with history of infertility. Three modalities namely Ziehl-Neelsen staining, Automated liquid culture and Nucleic acid amplification technique (TB-PCR) were compared and their sensitivity in diagnosis of genital tuberculosis was ascertained.

RESULTS

Out of 438 samples, 18 samples were found positive with at least one modality. TB-PCR positivity was 3.6% (16 cases) in comparison to culture where positivity was 1.59% (7 cases). Five samples were found culture and TB-PCR positive and only one sample was positive by all three diagnostic tests.

CONCLUSION

Infertility in young female per se is usually heart breaking and distressing. Therefore, it is essential to diagnose and treat the cases of genital tuberculosis before irreversible damage of tube may happen. Although, advancement in diagnostic field is there from microscopy to molecular method, but still diagnosis of genital tuberculosis is challenging. Correct diagnosis prevents young female from mental trauma and toxicity of anti-tuberculosis drugs given on suspicion in high prevalence country like India.

Isolated ovarian tuberculosis in an Immuno- competent woman in the post partum period: case report

Background

Pelvic tuberculosis is a rare form of extrapulmonary tuberculosis. It commonly involves the fallopian tubes and the uterus from a lympho-hematogeneous spread. The presentation of pelvic tuberculosis as an isolated ovarian abscess is extremely rare and is reported only twice.

Case presentation

a 25 yrs. old para III mother in the post partum period undergone laparotomy for suspected tuboovarian abscess/ovarian tumor after presenting with abdominal pain, pelvic mass and fever. Intra-operatively, Isolated right ovarian mass with caseation in the cavity but no significant pelvic adhesions was detected and right oophorectomy was done. Post operative Histopathology of surgical specimens revealed tuberculous leision and patient recovered well after anti-tuberculosis treatment.

Conclusion

Isolated ovarian tuberculosis is a very rare form of Genital Tuberculosis which should always be considered in the evaluation of a woman presenting with any adnexal mass in highly prevalent areas.

Pelvic tuberculosis: a forgotten diagnosis - case report

We present a case of a 14-year-old girl, Bacillus Calmette-Guérin (BCG) vaccinated, who presented with vague symptoms of abdominal pain, weight loss, and fatigue. Imaging studies revealed a pelvic mass, later found to be pelvic tuberculosis, a rare diagnosis to consider at this age. The diagnostic approach was difficult, since all investigations pointed strongly to a malignancy, from clinical, imaging (ultrasound and magnetic resonance), laboratory (elevated CA-125), and even macroscopic findings at laparotomy. Histopathology was the first hint (noncaseous granulomata), but the ultimate documentation of Mycobacterium tuberculosis relied on a persistent clinical suspicion, despite contradicting results. Surgical approach could have been mutilating, with irreversible consequences, considering it was a girl with a long reproductive life ahead. Tuberculosis is still a great masquerade, especially the extrapulmonary forms, and although infrequently seen at this age, it should thus be considered in the differential diagnosis of complex pelvic masses in order to avoid surgical iatrogeny/morbidity.

NMR-based metabonomics for understanding the influence of dormant female genital tuberculosis on metabolism of the human endometrium

STUDY QUESTION

Does investigation of metabolic perturbations in endometrial tissue of women with dormant genital tuberculosis (GTB) during the window of implantation (WOI) assist in improving the understanding of endometrial receptivity?

SUMMARY ANSWER

In dormant GTB cases significant alterations in endometrial tissue metabolites occur, largely related to energy metabolism and amino acid biosynthesis in dormant GTB cases.

WHAT IS KNOWN ALREADY

As an intracellular pathogen, Mycobacterium tuberculosis strongly influences the metabolism of host cells causing metabolic dysregulation. It is also accepted that dormant GTB impairs the receptive status of the endometrium. Global metabolic profiling is useful for an understanding of disease progression and distinguishing between diseased and non-diseased groups.

STUDY DESIGN, SIZE, DURATION

Endometrial tissue samples were collected from patients reporting at the tertiary infertility care center during the period September 2011-March 2013. Women having tested positive for GTB were considered as the study group (n = 24). Normal healthy women undergoing sterilization (n = 26) and unexplained infertile women with repeated IVF failure (n = 21) volunteered to participate as controls.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Endometrial tissue samples were collected 6-10 days after confirmation of ovulation. PCR and BACTEC-460 culture were used for diagnosing GTB. Proton nuclear magnetic resonance (1H NMR) spectra of tissue were recorded using a 700 MHz Bruker Avance AV III spectrometer. Following phase and baseline correction of all NMR spectra by Bruker Topspin 2.1 software, spectral peak alignment of the data was performed. Multivariate analysis was applied to all spectra and individual metabolites identified and multiple correlation analysis was performed.

MAIN RESULTS AND THE ROLE OF CHANCE

Leucine, isoleucine, acetate, lactate, glutamate, glutamine, methionine, lysine, creatine, glycogen, glycine, proline and choline were found to be significantly increased (P < 0.05) in endometrial tissue of women with dormant GTB compared with unexplained infertile women with repeated implantation failure. Valine, citrate, succinate and aspartate were also observed to be significantly up-regulated (P < 0.01). Furthermore, a significant decrease in glucose (P < 0.05), threonine (P < 0.05), tyrosine (P < 0.01) and phenylalanine (P < 0.0001) was observed in women with dormant GTB. Pearson's correlation analysis between the expression of various endometrial receptivity markers and metabolites showed a significant negative correlation (-0.236 to -0.545, P < 0.05). Also, the metabolites were positively correlated with endometrial receptivity markers (0.207 to 0.618, P < 0.05).

LIMITATIONS, REASONS FOR CAUTION

It is often difficult to diagnose dormant GTB because it tends to exist without any clinical signs or symptoms. In addition, the diagnosis of GTB by culture remains a challenge due to low detection rates and its paucibacillary nature. Testing for prostate-specific antigen or the Y chromosome in order to account for the possible influences of recent exposure to semen on endometrial metabolism would be important.

WIDER IMPLICATIONS OF THE FINDINGS

The metabolic changes associated with the dormant tubercle infection are of potential relevance to clinicians for the treatment of dormant GTB-related infertility.

STUDY FUNDING/COMPETING INTERESTS

Government of India, Indian Council of Medical Research. There are no conflicts of interest.

[The impact of tuberculosis and chemotherapy on female reproductive health]

The paper outlines a concise review of Russian and foreign literature on the specific features of the course of respiratory tuberculosis in reproductive-aged women. It shows the impact of active tuberculosis and massive chemotherapy on the reproductive system, analyzes clinical symptoms, immediate and long-term consequences, and prognosis of future reproductive function. The timely diagnosis and optimal correction of reproductive disorders in women with respiratory tuberculosis can improve their quality of life, fertile capacities, and birth of a successive healthy offspring.

A Rare Case of Flare-Up of PID in Infertility Treatment

Case Presentation. Mrs. X, 35 years old, case of primary infertility, was diagnosed to have genital tuberculosis on the basis of PCR positive and hysterolaparoscopy findings and received category I ATT for 6 months. Following ATT completion, her USG revealed no evidence of tuboovarian mass or hydrosalpinx. Since her tubes were patent, she underwent 3 cycles of ovulation induction and 2 cycles of IUI. The women presented with acute PID, five days after IUI, and was conservatively managed. She again presented 24 days after IUI with persistent low grade fever and abdominal pain. Suspecting relapse of genital tuberculosis, she was started on category II ATT. She had acute episodes of high grade fever with chills 2 weeks after starting ATT and MRI revealed bilateral TO masses suggestive of pyosalpinx. Emergency laparotomy was done, pus was drained, and cyst wall was removed and HPE was suggestive of chronic inflammation with few granulation tissues. ATT was continued for one year and the woman improved. Conclusion. The possibility of flare-up of PID (pelvic inflammatory disease) in treated case of tuberculosis undergoing infertility management should be kept in mind and aggressive management should be done.

Genitourinary tuberculosis: an atypical clinical presentation

Genitourinary tuberculosis is one of the common forms of extrapulmonary tuberculosis. We report a case of atypical genitourinary tuberculosis: massive uterovaginal prolapse with cervical lesion mimicking cervical carcinoma. This particular case highlights the problem of healthcare in most of the developing countries. Lack of patient education, awareness, and access to a healthcare system resulted in a complicated situation. In an endemic area or in an immunocompromised individual, a higher index of suspicion would allow early recognition and treatment institution to minimise its late consequences as well as spreading of the disease. Though anti-TB is the mainstay of treatment, surgical intervention might be needed in selected cases.

Clinical presentation and epidemiology of female genital tuberculosis in eastern Sudan

OBJECTIVE

To describe the epidemiology and clinical presentation of female genital tuberculosis (FGTB) among women in eastern Sudan.

METHODS

A cross-sectional survey was conducted at Kassala Maternity Hospital, Sudan, from January 1 to December 31, 2010.

RESULTS

Of the 2778 women presenting with various gynecologic symptoms, 44 suspected cases of FGTB were identified. Granulomatous tissue reactions were observed in 25 of the suspected FGTB cases, yielding an incidence of 0.9%. The majority (20/25; 80%) of these patients presented with chronic pelvic and lower abdominal pain; however, 68.0% (17/25) presented with pelvic mass, cyst and/or abscess; 48.0% (12/25) had dyspareunia; 40.0% (10/25) were infertile; 28% (7/25) had menstrual dysfunction; 20.0% (5/25) had dysmenorrhea; and 4.0% (1/25) experienced postmenopausal bleeding. Body mass index, residence, and educational level were significantly different between women diagnosed with FGTB and those where FGTB was excluded (P values=0.02, 0.03, and 0.01, respectively). However, no significant differences were found in age and Bacillus Calmette-Guérin vaccination status.

CONCLUSION

Clinical suspicion may facilitate and improve the detection of FGTB, with chronic pelvic pain identified as the predominant clinical presentation among women in eastern Sudan.

Tubercular tubo-ovarian cystic mass mimicking acute appendicitis: a case report

INTRODUCTION

Female genital tuberculosis is a rare form of extrapulmonary tuberculosis. It is an asymptomatic disease usually diagnosed during the search for causes of infertility. However, it can present with a number of abdominopelvic symptoms. Herein we report a case of tubo-ovarian tuberculosis mimicking acute appendicitis.

CASE PRESENTATION

A 17-year-old single Turkish woman presented to our hospital with complaints of right lower quadrant abdominal pain, nausea, and vomiting. Her physical examination findings, ultrasonogram, and leukocyte count were consistent with acute appendicitis. A cystic mass (15 cm × 6 cm) was detected on the right tubo-ovarian structure by laparotomy. The mass was excised while the tubo-ovarian structures were preserved and the need for an appendectomy was avoided. No microbiological evaluation was performed. The histopathological examination of the cystic mass revealed a granuloma with central caseating necrosis surrounded by epithelioid histiocytes. The patient was treated with anti-tuberculosis therapy for six months. No recurrence was observed during a 10-month follow-up period.

CONCLUSION

Genital tuberculosis should be considered in the differential diagnosis of right lower quadrant pain in women who live in tuberculosis-endemic regions.

Association of tuberculous endometritis with infertility and other gynecological complaints of women in India

Endometrial biopsy samples derived from 393 patients with assorted gynecological complaints were investigated for mycobacterial infection. By employment of four different techniques, mycobacterial pathogens were detected irrespective of the nature/type of clinical complaint. Mycobacterium tuberculosis was the predominant pathogen detected among the samples investigated.