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Unusual presentations of genital tract tuberculosis
171
Int. J. Gynecol. Obstet., 1190,33: 171-176 International Federation of Gynecoloey and Obstetrics
Unusual presentations of genital tract tuberculosis J.R. Carter King George V H-pita& Royal Prince Auked Hospital, Camperdown, NS W 2050 (Australia) (Received May 3rd. 1989) (Revised and accepted August 2nd. 1989)
Abstract Three cases of genital tract tuberculosis (GTB) are described. This disease is uncommon in developed countries. Patients may present with infertility, non-specific menstrual disturbance, pain or abdominal distention. The genital tract is usually infected by hematogenous spread from a distant focus, with the fallopian tubes most commonly involved. Diagnosis is often made retrospectively, and once corlfirmed medical management is the mainstay of treatment. Future fertility is doubtful in these patients. Keywords: Genital tract tuberculosis; Cervical tuberculosis; Ascites; Myobacterium tuberculosis. Introduction While the clinical features and infectivity of tuberculosis were known well before 1000 BC, the term tuberculosis was used for the first time in 1834 [14]. Morgani in the mideighteenth century was the first person to describe genital tuberculosis. It was over a century later that Koch in 1882 discovered the tubercle bacillus [l 11. No other infective disease has infected so many people over the years, and despite adequate screening and treatment, still remains an important communicable disease throughout the world. Genital tract tuberculosis (GTB) is a rela002CL7292/9O/SO3.50 0 1990 International Federation of Gynecology and Obstetrics Published and Printed in Ireland
tively common condition in undeveloped countries [6], and with changing migration patterns is being seen with increasing frequency in developed countries [2]. Diagnosis is not often considered until histological examination reveals the typical tuberculoid granulomas [ 141. Case reborts Cuse 1 The patient, a 30-year-old Tahitian with 2 children, was admitted to hospital with a 2month history of tiredness, non-specific abdominal pain and abdominal distention, weight loss and low grade temperature. Her menstrual cycles were irregular over the preceding 3 months. She had been living in Australia for the previous 13 years and worked as a Travel Consultant. She had no relevant past medical or surgical history. She denied ever having TB, or being in contact with it and had no family history of the disease. Examination revealed a healthy looking woman. She had marked ascities. Pelvic examination was noncontributory. Paracentesis revealed an increased white cell count, no AFB and no malignant cells. A laparoscopy and curettage revealed widespread miliary deposits over the entire pelvic peritoneum. The uterus was the fallopian tubes slightly enlarged, edematous and ovaries, apart from miliary deposits, were otherwise normal. Frozen section of a biopsy of the pelvic peritoneum revealed a typical tuberculoid granuloma. Case Report
172
Carter
Subsequent histology on these peritoneal deposits and endometrial curettings revealed numerous granulomatous tubercles (Fig. 1). Subsequent investigations performed include a chest X-ray which was normal, a midstream urine for culture which was also negative. Members of her family were screened and she was commenced on isoniazid, rifampicin, ethambutal, pyrazinamide and pyridoxine. Case 2 A 48-year-old woman presented with a 2year history of menorrhagia. A curettage performed previously revealed normal secretory endometrium. Her past history included a left mastectomy 5-years earlier for carcinoma of the breast. She was raised in the United King-
Fig. 1. Fibro-fatty subperitoneal tissue containing small well formed granuloma with a chronic inflammatory cell infiltrate (H&E, x 120). Int JGynecol Obstet 33
dom and migrated to Australia in her adult years. As a child, she remembered her cousins being treated for tuberculosis. Prior to arriving in Australia she lived for 2 years in Singapore. Her tuberculosis screen on arriving in Australia was negative. General physical examination was unremarkable, while pelvic examination revealed a 20-week size fibroid uterus. At laparotomy an enlarged fibroid uterus was confirmed, both fallopian tubes were enlarged and engorged. Both ovaries were also enlarged and cystic. A total abdominal hysterectomy and bilateral salpingo-oophorectomy and omentectomy was performed because of concern of her history of breast carcinoma. Histology revealed a thickened endometrium with a florid granulomatous reaction with multiple giant cells of Langhans type and areas of necrosis (Fig. 2). Small granulomas were also present within the myometrium and within the cervical stroma. Both fallopian tubes showed florid necrotising granulomatous inflammation with associated gross reactive hyperplastic epithelial changes causing considerable distortion of architecture. Granulomas were also present throughout the thickness of the tubal wall and also on the serosal surface (Fig. 3). Special stains failed to identify acid-fast bacilli. Investigations reveal a positive Mantoux test, negative cultures of urine for acid-fast bacilli and a normal chest X-ray. She was commenced on isoniazid, rifampicin and ethambutal. Case 3 A 33-year-old Vietnamese immigrant was referred to the Colposcopy Clinic with an abnormal appearing cervix. She had been attending the Fertility Clinic with secondary infertility, oligomenorrhea, dyspareunia and a 6-month history of postcoital bleeding. Her menstrual cycles were irregular every 2-3 months with light menses lasting only l-2 days. Prior to arriving in Australia she had spent 12 months in a refugee camp in Hong Kong. She denied a past history of and contact with tuberculosis. Her hsitory was other-
Genital tract tuberculosis
Fig. 2. Uterine wall showing diffuse florid adenomyosis with proliferating glands and two well formed granulomas, with multiple giant cells of Langhan’s type and areas of necrosis (H &E, x 120).
wise unremarkable, denying malaise, weight loss, night sweats or other constitutional symptoms. General examination was unremarkable. Pelvic examinations revealed a slightly enlarged mobile uterus, with associated tenderness in the Pouch of Douglas. There were no adnexal masses or tenderness. Speculum examination revealed an abnormal cervix which exhibited marked contact bleeding. On the posterior lip of the cervix was an irregular large exophytic fleshy lesion. A Papanicolaou smear was performed and colposcopy and biopsy performed. Colposcopy confirmed the above findings and a directed biopsy was taken from the lesion on the posterior lip of the cervix revealing a tuberculoid
173
Fig. 3. Fallopian tube showing florid necrotising granulomatous inflammation with associated gross reactive hyperplastic epithelial changes causing considerable distortion of architecture and a pseudoepitheliomatous hyperplasia of the tubal mucosa (H &E, x 120).
granuloma as depicted in Fig. 4. Culture of fresh cervical tissue proved negative for acidfast bacilli. Also negative were sputum cultures, urine cultures and chest X-ray. The patient’s husband was also screened for acidfast bacilli. Triple chemotherapy consisting of rifampicin, ethambutol and isoniazid was commenced. Six weeks later repeat colposcopy revealed significant resolution of her cervical disease with a negative cervical biopsy. Discussion Genital tract tuberculosis (GTB) is uncommon in developed countries. Reported incidCase Report
Fig. 4.
The cervical biopsy with intact cervical epithelium shows a heavy inflammatory cell infiltrate with a tuberculoid granuloma. Multiple multinucleated giant cells of Langhans type were present and some of the granulomas showed central caseation (H & E, x 120).
ence rates vary from less than 1% in Australia up to 19% in India [ 113. An accurate estimation of the incidence of GTB in a population is difficult to determine due to the large pool of infected asymptomatic carriers [l]. Changing migration patterns accounts for its continued detection in developed countries [2,4,5]. Although the overall incidence of pulmonary tuberculous has been decreasing, the number of new cases reported has increased by as much as 36% in the United 1970-1974 States during the years [5,10,11,13]. In developed countries, genital tract tuberculosis is more common in young patients, Int JGynecol Obstet 33
often due to their presentation to fertility clinics and hence subsequent earlier diagnosis [3,4]. In lo-20% of cases, GTB occurs in older women where there is probably late hematogenous spread to pelvic organs rather than persistence of a pelvic infection acquired in earlier life [4]. The reverse seems to be true in developing countries, where most cases of GTB tend to occur in older age groups [4,14]. The genital tract is usually infected from a focus elsewhere in the body, usually the lung [2,3]. Fourteen to 33% of patients with pulmonary tuberculosis will also have GTB [ 131. Dissemination occurs by hematogenous spread, by lymphatic spread or rarely by direct local extension. Very rarely may GTB be acquired as a primary infection, sexually transmitted from an infected partner with tuberculous epididymoorchitis [ 121. The fallopian tubes are the most common sites for genital infection [2,5]. Then usually by direct extension the ovaries, uterus, cervix and vagina are infected in decreasing frequency. Reported rates of infection of the pelvic organs in GTB are: fallopian tubes 90-100%; uterus 50%; ovaries 30%; cervix 5-15070; and vagina 1% [12]. The macroscopic appearance of tuberculous salpingitis is non-specific and often the diagnosis is made retrospectively after microscopic examination of tissue specimens. Sometimes the tubal serosa is studded with multiple tuberculous granulomas as may the parietal peritoneum, and when associated with ascites is highly suggestive of tuberculosis or other granulomatous disease. The falwith lopian tubes may be indurated multifocal obstruction and densely adherent to adjacent structures. More commonly the gross appearance of tuberculosis salpingitis is similar to that of chronic salpingitis of nontuberculosis nature with a chronic interstitial salpingitis, follicular pyosalpinx, or hydrosalpinx or salpingitis isthmica nodosa
181. In tuberculous salpingitis, as opposed to other causes of salpingitis, the fimbrial end of the tube often remains patent and the fimbria
Genital tract tuberculosis
everted producing the so-called tobacco pouch appearance [lo]. Microscopic diagnosis of GTB involves indentification of the typical chronic inflammatory granuloma of lymphocytes with central giant cells and surrounding epithelioid cells [8]. Caseation may be noted in the acute phase of the infection [ 131. Symptoms vary from non-specific lower abdominal pain, infertility, menstrual abnormalities, including oligomenorrhoea, amenorrhoea and menorrhagia [2,12]. Uncommonly, abdominal distention, ascites, profuse watery vaginal discharge, postcoital, postmenopausal and intermenstrual bleeding. Malaise and other constitutional symptoms of infection are often present. Pelvic examination is usually non-specific. Occasionally characteristic masses of doughy consistency are found WI. The diagnosis of GTB is usually not suspected until microscopic examination of specimen reveals granuloma [ 1,5]. Investigation involves confirmation of the diagnosis and exclusion of systemic disease. Other causes of granulomatous disease include sarcoid, and foreign body brucellosis, tularemia reaction, and are usually easily excluded [5]. endometrial curettings Premenstrual should be examined histologically and cultured for acid fast bacilli (AFB). Repeated cultures are often necessary to obtain a positive result, although a positive culture is not essential for disgnosis [3,5]. A positive result can be expected in 50% of cases. Repeated sampling of the endometrium unfortunately has the disadvantage of exacerbating an acute infection. A CXR to exclude pulmonary tuberculosis will detect disease in less than 30% of patients. Tuberculin skin testing, when negative may be useful to rule out exposure to the tubercle bacillus, although false negative reations occur in a variety of conditions. A positive tuberculin skin test while consistent with exposure to the tubercle bacillus, fails to localize the disease [2]. Urine culture for AFB is useful if urinary disease is suspected.
175
The hysterosalpingogram (HSG) is frequently abnormal in GTB, but unfortunately its positive predictive value is low. Abnormalities detected in patients with GTB include: tubal obstruction, multiple constrictions, grape-like sacculations and rigid “stove pipe” fallopian tubes. The endometrial cavity may be distorted by intrauterine adhesions and calcified pelvic lymph nodes might also be visible [2,5]. Unfortunately many of these abnormalities are indistinguishable from those produced by bacterial tubal obstruction, salpingitis isthmica nodosa or tubal endometriosis. Treatment aims at eradication of infected foci and control of systemic disease. Medical management remains the mainstay of therapy in GTB. Prior to the initiation of treatment, the extent of pelvic disease and presence of active extragenital lesions needs to be determined. Close contacts need to be identified and screened for disease. Medical management involves combination antituberculous chemotherapy. In vitro susceptibility testing determines the appropriate combination of the following antimicrobial agents: rifampicin, isoniazid, ethambutal and streptomicin. Complete physical and mental rest, proper nutrition, dietary supplements and careful personal hygiene are also important [2,12]. Treatment is prolonged with a minimum of 2 years sometimes necessary for adequate treatment. Throughout the treatment period endometrial curettings are examined bacteriologically and microscopically [3,12]. If positive, the addition of additional drugs to the treatment is necessary. Surgery is not rare in the management of GTB. With more effective medical therapy, surgery is not only indicated for persistence or progression of disease despite adequate medical treatment, for recurrence of disease shortly after ceasing medical treatment, and for fistulas that fail to heal [4,5,7,12]. Controversy exists over the fertility of patients after being treated for GTB [3]. Where the endometrial cavity has been Case Report
176
Carter
destroyed, or fallopian tubes irreparably damaged, spontaneous conception is unlikely. Although IVF and related techniques are theoretically possible for patients with tubal disease only [ 121, there are no reports of successful pregnancies with these methods. Some have attempted microsurgical tuboplasties in these patients, again successful pregnancy is unlikely. A few cases of ectopic pregnancy have been reported. Le Blanc reported on 51 tuboplasty procedures on patients with GTB. The postoperative tubal patency rate was 25%. There were no subsequent intrauterine pregnancies and 1 tubal pregnancy [7]. Reactivation of latent tubal infection remains a complication of this .procedure. Successful intrauterine pregnancy seems only likely if medical management is promptly instituted in a patient with early disease, with no sequelae or ovarian, tubal or endometrial function [2]. In 1964, Schaefer reviewed the world literature on over 7000 reported cases of GTB and found only 31 adequately documented cases of GTB associated with subsequent successful pregnancies 191. Genital tract tuberculosis is rarely in gynecological practice. encountered Although often made retrospectively, the diagnosis should be considered in young immigrant patients presenting with either infertility, or non-specific menstrual disturbance, pain or abdominal distention.
ht JGynecol
Obstet 33
References
4 5 6 7 8
9
10 11 12
13
14
Barbour EM: Post menopausal endometrial tuberculosis. J Obstet Gynaecol Br Emp 67: 1008,196O. Bateman BG, Nunley WC et al: Genital tuberculosis in reproductive age women. J Reprod Med 31: 287.1986. Chattopadhyay SK Sengupta BS, Edrees YB et al: The pattern of female genital tuberculosis in Riyadh, Saudia Arabia. Br J Obstet Gynaecol93: 367,1986. Hutchins CJ: Tuberculosis of the female genital tract-a changing picture. Br J Obstet Gynaecol84: 534, 1977. Klein TA, Richmond JA, Mishell DR: Pelvic tuberculosis. Obstet Gynecol48: 99,1976. Koller AB: Granulomatous lesions of the cervix uteri in black patients. S Afr Med J 49: 1228,1975. LeBlanc EJ: Technique and results of salpingostomies. Fertil Steril IO:412, 1959. Novak ER, Woodruff JD: In: Novak’s Gynecologic and Obstetric Pathology, 8th edn, pp 96-97. WB Saunders, Philadelphia, PA, 1979. Schaefer G: Full term pregnancy following genital tuberculosis. Obstet Gynecol, Surv 19: 81. 1964. Schaefer G: Tuberculosis of the female genital tract. Clin Obstet Gynecol13: %5,1970. Schaefer G: Female genital tuberculosis. Clin Obstet Gynecol19: 223, 1976. Sutherland AM: Gynaecological tuberculosis: analysis of a personal series of 710 cases. Aust NZ J Obstet Gynaecol 25: 203,1985. Tripathy SN, Tripathy SN: Genital manifestations of pulmonary tuberculosis. Int J Gynecol Obstet 19: 391, 1981. Ylinen 0: Genital tuberculosis in women. Acta Obstet Gynecol Stand (suppl2) 60: 1, 1%1.
Address for reprints: J.R. Carter King George V Memorial Hospital Camperdown, NSW Australia, 2050
Int. J. Gynecol. Obstet., 1190,33: 171-176 International Federation of Gynecoloey and Obstetrics
Unusual presentations of genital tract tuberculosis J.R. Carter King George V H-pita& Royal Prince Auked Hospital, Camperdown, NS W 2050 (Australia) (Received May 3rd. 1989) (Revised and accepted August 2nd. 1989)
Abstract Three cases of genital tract tuberculosis (GTB) are described. This disease is uncommon in developed countries. Patients may present with infertility, non-specific menstrual disturbance, pain or abdominal distention. The genital tract is usually infected by hematogenous spread from a distant focus, with the fallopian tubes most commonly involved. Diagnosis is often made retrospectively, and once corlfirmed medical management is the mainstay of treatment. Future fertility is doubtful in these patients. Keywords: Genital tract tuberculosis; Cervical tuberculosis; Ascites; Myobacterium tuberculosis. Introduction While the clinical features and infectivity of tuberculosis were known well before 1000 BC, the term tuberculosis was used for the first time in 1834 [14]. Morgani in the mideighteenth century was the first person to describe genital tuberculosis. It was over a century later that Koch in 1882 discovered the tubercle bacillus [l 11. No other infective disease has infected so many people over the years, and despite adequate screening and treatment, still remains an important communicable disease throughout the world. Genital tract tuberculosis (GTB) is a rela002CL7292/9O/SO3.50 0 1990 International Federation of Gynecology and Obstetrics Published and Printed in Ireland
tively common condition in undeveloped countries [6], and with changing migration patterns is being seen with increasing frequency in developed countries [2]. Diagnosis is not often considered until histological examination reveals the typical tuberculoid granulomas [ 141. Case reborts Cuse 1 The patient, a 30-year-old Tahitian with 2 children, was admitted to hospital with a 2month history of tiredness, non-specific abdominal pain and abdominal distention, weight loss and low grade temperature. Her menstrual cycles were irregular over the preceding 3 months. She had been living in Australia for the previous 13 years and worked as a Travel Consultant. She had no relevant past medical or surgical history. She denied ever having TB, or being in contact with it and had no family history of the disease. Examination revealed a healthy looking woman. She had marked ascities. Pelvic examination was noncontributory. Paracentesis revealed an increased white cell count, no AFB and no malignant cells. A laparoscopy and curettage revealed widespread miliary deposits over the entire pelvic peritoneum. The uterus was the fallopian tubes slightly enlarged, edematous and ovaries, apart from miliary deposits, were otherwise normal. Frozen section of a biopsy of the pelvic peritoneum revealed a typical tuberculoid granuloma. Case Report
172
Carter
Subsequent histology on these peritoneal deposits and endometrial curettings revealed numerous granulomatous tubercles (Fig. 1). Subsequent investigations performed include a chest X-ray which was normal, a midstream urine for culture which was also negative. Members of her family were screened and she was commenced on isoniazid, rifampicin, ethambutal, pyrazinamide and pyridoxine. Case 2 A 48-year-old woman presented with a 2year history of menorrhagia. A curettage performed previously revealed normal secretory endometrium. Her past history included a left mastectomy 5-years earlier for carcinoma of the breast. She was raised in the United King-
Fig. 1. Fibro-fatty subperitoneal tissue containing small well formed granuloma with a chronic inflammatory cell infiltrate (H&E, x 120). Int JGynecol Obstet 33
dom and migrated to Australia in her adult years. As a child, she remembered her cousins being treated for tuberculosis. Prior to arriving in Australia she lived for 2 years in Singapore. Her tuberculosis screen on arriving in Australia was negative. General physical examination was unremarkable, while pelvic examination revealed a 20-week size fibroid uterus. At laparotomy an enlarged fibroid uterus was confirmed, both fallopian tubes were enlarged and engorged. Both ovaries were also enlarged and cystic. A total abdominal hysterectomy and bilateral salpingo-oophorectomy and omentectomy was performed because of concern of her history of breast carcinoma. Histology revealed a thickened endometrium with a florid granulomatous reaction with multiple giant cells of Langhans type and areas of necrosis (Fig. 2). Small granulomas were also present within the myometrium and within the cervical stroma. Both fallopian tubes showed florid necrotising granulomatous inflammation with associated gross reactive hyperplastic epithelial changes causing considerable distortion of architecture. Granulomas were also present throughout the thickness of the tubal wall and also on the serosal surface (Fig. 3). Special stains failed to identify acid-fast bacilli. Investigations reveal a positive Mantoux test, negative cultures of urine for acid-fast bacilli and a normal chest X-ray. She was commenced on isoniazid, rifampicin and ethambutal. Case 3 A 33-year-old Vietnamese immigrant was referred to the Colposcopy Clinic with an abnormal appearing cervix. She had been attending the Fertility Clinic with secondary infertility, oligomenorrhea, dyspareunia and a 6-month history of postcoital bleeding. Her menstrual cycles were irregular every 2-3 months with light menses lasting only l-2 days. Prior to arriving in Australia she had spent 12 months in a refugee camp in Hong Kong. She denied a past history of and contact with tuberculosis. Her hsitory was other-
Genital tract tuberculosis
Fig. 2. Uterine wall showing diffuse florid adenomyosis with proliferating glands and two well formed granulomas, with multiple giant cells of Langhan’s type and areas of necrosis (H &E, x 120).
wise unremarkable, denying malaise, weight loss, night sweats or other constitutional symptoms. General examination was unremarkable. Pelvic examinations revealed a slightly enlarged mobile uterus, with associated tenderness in the Pouch of Douglas. There were no adnexal masses or tenderness. Speculum examination revealed an abnormal cervix which exhibited marked contact bleeding. On the posterior lip of the cervix was an irregular large exophytic fleshy lesion. A Papanicolaou smear was performed and colposcopy and biopsy performed. Colposcopy confirmed the above findings and a directed biopsy was taken from the lesion on the posterior lip of the cervix revealing a tuberculoid
173
Fig. 3. Fallopian tube showing florid necrotising granulomatous inflammation with associated gross reactive hyperplastic epithelial changes causing considerable distortion of architecture and a pseudoepitheliomatous hyperplasia of the tubal mucosa (H &E, x 120).
granuloma as depicted in Fig. 4. Culture of fresh cervical tissue proved negative for acidfast bacilli. Also negative were sputum cultures, urine cultures and chest X-ray. The patient’s husband was also screened for acidfast bacilli. Triple chemotherapy consisting of rifampicin, ethambutol and isoniazid was commenced. Six weeks later repeat colposcopy revealed significant resolution of her cervical disease with a negative cervical biopsy. Discussion Genital tract tuberculosis (GTB) is uncommon in developed countries. Reported incidCase Report
Fig. 4.
The cervical biopsy with intact cervical epithelium shows a heavy inflammatory cell infiltrate with a tuberculoid granuloma. Multiple multinucleated giant cells of Langhans type were present and some of the granulomas showed central caseation (H & E, x 120).
ence rates vary from less than 1% in Australia up to 19% in India [ 113. An accurate estimation of the incidence of GTB in a population is difficult to determine due to the large pool of infected asymptomatic carriers [l]. Changing migration patterns accounts for its continued detection in developed countries [2,4,5]. Although the overall incidence of pulmonary tuberculous has been decreasing, the number of new cases reported has increased by as much as 36% in the United 1970-1974 States during the years [5,10,11,13]. In developed countries, genital tract tuberculosis is more common in young patients, Int JGynecol Obstet 33
often due to their presentation to fertility clinics and hence subsequent earlier diagnosis [3,4]. In lo-20% of cases, GTB occurs in older women where there is probably late hematogenous spread to pelvic organs rather than persistence of a pelvic infection acquired in earlier life [4]. The reverse seems to be true in developing countries, where most cases of GTB tend to occur in older age groups [4,14]. The genital tract is usually infected from a focus elsewhere in the body, usually the lung [2,3]. Fourteen to 33% of patients with pulmonary tuberculosis will also have GTB [ 131. Dissemination occurs by hematogenous spread, by lymphatic spread or rarely by direct local extension. Very rarely may GTB be acquired as a primary infection, sexually transmitted from an infected partner with tuberculous epididymoorchitis [ 121. The fallopian tubes are the most common sites for genital infection [2,5]. Then usually by direct extension the ovaries, uterus, cervix and vagina are infected in decreasing frequency. Reported rates of infection of the pelvic organs in GTB are: fallopian tubes 90-100%; uterus 50%; ovaries 30%; cervix 5-15070; and vagina 1% [12]. The macroscopic appearance of tuberculous salpingitis is non-specific and often the diagnosis is made retrospectively after microscopic examination of tissue specimens. Sometimes the tubal serosa is studded with multiple tuberculous granulomas as may the parietal peritoneum, and when associated with ascites is highly suggestive of tuberculosis or other granulomatous disease. The falwith lopian tubes may be indurated multifocal obstruction and densely adherent to adjacent structures. More commonly the gross appearance of tuberculosis salpingitis is similar to that of chronic salpingitis of nontuberculosis nature with a chronic interstitial salpingitis, follicular pyosalpinx, or hydrosalpinx or salpingitis isthmica nodosa
181. In tuberculous salpingitis, as opposed to other causes of salpingitis, the fimbrial end of the tube often remains patent and the fimbria
Genital tract tuberculosis
everted producing the so-called tobacco pouch appearance [lo]. Microscopic diagnosis of GTB involves indentification of the typical chronic inflammatory granuloma of lymphocytes with central giant cells and surrounding epithelioid cells [8]. Caseation may be noted in the acute phase of the infection [ 131. Symptoms vary from non-specific lower abdominal pain, infertility, menstrual abnormalities, including oligomenorrhoea, amenorrhoea and menorrhagia [2,12]. Uncommonly, abdominal distention, ascites, profuse watery vaginal discharge, postcoital, postmenopausal and intermenstrual bleeding. Malaise and other constitutional symptoms of infection are often present. Pelvic examination is usually non-specific. Occasionally characteristic masses of doughy consistency are found WI. The diagnosis of GTB is usually not suspected until microscopic examination of specimen reveals granuloma [ 1,5]. Investigation involves confirmation of the diagnosis and exclusion of systemic disease. Other causes of granulomatous disease include sarcoid, and foreign body brucellosis, tularemia reaction, and are usually easily excluded [5]. endometrial curettings Premenstrual should be examined histologically and cultured for acid fast bacilli (AFB). Repeated cultures are often necessary to obtain a positive result, although a positive culture is not essential for disgnosis [3,5]. A positive result can be expected in 50% of cases. Repeated sampling of the endometrium unfortunately has the disadvantage of exacerbating an acute infection. A CXR to exclude pulmonary tuberculosis will detect disease in less than 30% of patients. Tuberculin skin testing, when negative may be useful to rule out exposure to the tubercle bacillus, although false negative reations occur in a variety of conditions. A positive tuberculin skin test while consistent with exposure to the tubercle bacillus, fails to localize the disease [2]. Urine culture for AFB is useful if urinary disease is suspected.
175
The hysterosalpingogram (HSG) is frequently abnormal in GTB, but unfortunately its positive predictive value is low. Abnormalities detected in patients with GTB include: tubal obstruction, multiple constrictions, grape-like sacculations and rigid “stove pipe” fallopian tubes. The endometrial cavity may be distorted by intrauterine adhesions and calcified pelvic lymph nodes might also be visible [2,5]. Unfortunately many of these abnormalities are indistinguishable from those produced by bacterial tubal obstruction, salpingitis isthmica nodosa or tubal endometriosis. Treatment aims at eradication of infected foci and control of systemic disease. Medical management remains the mainstay of therapy in GTB. Prior to the initiation of treatment, the extent of pelvic disease and presence of active extragenital lesions needs to be determined. Close contacts need to be identified and screened for disease. Medical management involves combination antituberculous chemotherapy. In vitro susceptibility testing determines the appropriate combination of the following antimicrobial agents: rifampicin, isoniazid, ethambutal and streptomicin. Complete physical and mental rest, proper nutrition, dietary supplements and careful personal hygiene are also important [2,12]. Treatment is prolonged with a minimum of 2 years sometimes necessary for adequate treatment. Throughout the treatment period endometrial curettings are examined bacteriologically and microscopically [3,12]. If positive, the addition of additional drugs to the treatment is necessary. Surgery is not rare in the management of GTB. With more effective medical therapy, surgery is not only indicated for persistence or progression of disease despite adequate medical treatment, for recurrence of disease shortly after ceasing medical treatment, and for fistulas that fail to heal [4,5,7,12]. Controversy exists over the fertility of patients after being treated for GTB [3]. Where the endometrial cavity has been Case Report
176
Carter
destroyed, or fallopian tubes irreparably damaged, spontaneous conception is unlikely. Although IVF and related techniques are theoretically possible for patients with tubal disease only [ 121, there are no reports of successful pregnancies with these methods. Some have attempted microsurgical tuboplasties in these patients, again successful pregnancy is unlikely. A few cases of ectopic pregnancy have been reported. Le Blanc reported on 51 tuboplasty procedures on patients with GTB. The postoperative tubal patency rate was 25%. There were no subsequent intrauterine pregnancies and 1 tubal pregnancy [7]. Reactivation of latent tubal infection remains a complication of this .procedure. Successful intrauterine pregnancy seems only likely if medical management is promptly instituted in a patient with early disease, with no sequelae or ovarian, tubal or endometrial function [2]. In 1964, Schaefer reviewed the world literature on over 7000 reported cases of GTB and found only 31 adequately documented cases of GTB associated with subsequent successful pregnancies 191. Genital tract tuberculosis is rarely in gynecological practice. encountered Although often made retrospectively, the diagnosis should be considered in young immigrant patients presenting with either infertility, or non-specific menstrual disturbance, pain or abdominal distention.
ht JGynecol
Obstet 33
References
4 5 6 7 8
9
10 11 12
13
14
Barbour EM: Post menopausal endometrial tuberculosis. J Obstet Gynaecol Br Emp 67: 1008,196O. Bateman BG, Nunley WC et al: Genital tuberculosis in reproductive age women. J Reprod Med 31: 287.1986. Chattopadhyay SK Sengupta BS, Edrees YB et al: The pattern of female genital tuberculosis in Riyadh, Saudia Arabia. Br J Obstet Gynaecol93: 367,1986. Hutchins CJ: Tuberculosis of the female genital tract-a changing picture. Br J Obstet Gynaecol84: 534, 1977. Klein TA, Richmond JA, Mishell DR: Pelvic tuberculosis. Obstet Gynecol48: 99,1976. Koller AB: Granulomatous lesions of the cervix uteri in black patients. S Afr Med J 49: 1228,1975. LeBlanc EJ: Technique and results of salpingostomies. Fertil Steril IO:412, 1959. Novak ER, Woodruff JD: In: Novak’s Gynecologic and Obstetric Pathology, 8th edn, pp 96-97. WB Saunders, Philadelphia, PA, 1979. Schaefer G: Full term pregnancy following genital tuberculosis. Obstet Gynecol, Surv 19: 81. 1964. Schaefer G: Tuberculosis of the female genital tract. Clin Obstet Gynecol13: %5,1970. Schaefer G: Female genital tuberculosis. Clin Obstet Gynecol19: 223, 1976. Sutherland AM: Gynaecological tuberculosis: analysis of a personal series of 710 cases. Aust NZ J Obstet Gynaecol 25: 203,1985. Tripathy SN, Tripathy SN: Genital manifestations of pulmonary tuberculosis. Int J Gynecol Obstet 19: 391, 1981. Ylinen 0: Genital tuberculosis in women. Acta Obstet Gynecol Stand (suppl2) 60: 1, 1%1.
Address for reprints: J.R. Carter King George V Memorial Hospital Camperdown, NSW Australia, 2050