genital tuberculosis - how to diagnose & when to treat by dr shashwat jani

Dr. Shashwat Jani. M. S. ( Obs – Gynec ) , FIAOG.

Diploma in Advance Laparoscopy.

Consultant Assistant Professor, Smt. N.H.L. Municipal Medical College.

Sheth V. S. General Hospital , Ahmedabad.

Mobile : +91 99099 44160. E-mail : [email protected]

TUBERCULOSIS- A MAJOR THREAT

TO DEVELOPING COUNTRIES

Annual cases of T.B world wide - 8 million.

95% occur in developing countries.

Prevalence worldwide is 16-20 million, with 8-10 million

being sputum +ve.

No. of people infected with T.B bacilli approximately,

1.7 billion & 1.3 billion live in developing countries

Greatest burden of T.B.( incidence &mortality) in adults

aged 15-60 years

24-Dec-17 Dr Shashwat Jani. +91 99099 44160.

2

CONT….

• In India 40% adults infected with T.B , 1.5 million on Rx every year

• 5,00,000 deaths from T.B occur every year .

• Each smear +ve pt. can infect 10 -15 persons.

Central T.B division -DGHS, Ministry of health &Family welfare,New Delhi (June, 2000 )


3

INTRODUCTION

General Incidence – India -- FGTB

• Most common extra pulmonary TB

• 30 % of all extrapulmonary TB

• 18% of infertile women

• 11% of hematospermia

• 5-25 year after primary pulmonary TB


4

Causative Organism

• Mycobacterium tuberculosis • Human: 90-95%

• Bovine: 5-10%, higher incidence in rural India, unpausterised milk

• Atypical strain, rarely


5

Modes Of Infection

• Primary: rare, vulva & Cx, coitus?

• Secondary: always,

Pulmonary (9-10%),

Extra-pulmonary-bone, LN, urinary system, peritoneum

• Early transmission, slow course, 10-12yrs

• Hematogenous : 80%, Mainly tube

• Lymphatic: from peritoneum & mesenteric LN

• Direct: Peritoneum, pelvis, urinary system, Ls


6

SITES OF INFECTION

• Tub. Salpingitis: almost 100%, primary focus, often bilateral

• Uterus(Corpus): 50-60%, often secondary to tube

• Cervix: 4-6%

• Ovaries: 20-30%


7

Diagnosis

• Despite availability of various diagnostic

techniques, diagnostic dilemma still exists, especially for genital TB.

• Hence, FGTB needs a thorough systematic clinical examination with high degree of suspicion and use of intensive investigations.


8

9

FGTB – DIAGNOSTIC MODALITIES CLINICAL RADIOLOGICAL LABORATORY

Reliability increases with • Progression of disease • Multisystem involvement

Early changes • Needs confirmation Advanced disease • Almost diagnostic

Valuable for • Early disease diagnosis • Rapid diagnosis • Drugs sensitivity

INVASIVE – Endoscopy / Biopsy / Dye study


SYMPTOMATOLOGY

• Asymptomatic

• Constitutional Symptoms- Anorexia ,

Malaise, Evening Rise Of Temperature,

Weight Loss

• Infertility Due To Tubal Closure.

Primary -75% Cases

Secondary -14% cases following an

abortion , ectopic or normal delivery.


10

• Schaffer- Two types a) Silent / Latent type: Symptomless, no clinical finding,

proliferative changes in endosalpinx, adhesions between rugal folds, labyrinthine mases

b) Advanced: palpable masses

Menstrual Disorders- • Normal menstruation in 50-85% early cases • Dysmenorrhoea • Menorrhagia, menometrorrhagia due to ulcerative

T.B. endometritis • Late : Oligo-hypomenohea

24-Dec-17

Dr Shashwat Jani. +91 99099 44160.

11

Contd... • Amenorrhoea- (7% cases )

Due to destruction of endometrium & ovaries

- Io Amenorrhoea (40%)following 10

peritoneal T.B. in childhood

- II0Amen. (60%) following scanty periods

Diag.: SSC well developed, No response to EP,

No endometrium on D&C, HSG helpful

• Puberty Menorrhagia


12

Contd..

• Pain - Vague Abdominal Discomfort (Tb Peritonitis Or

Abscess), Ascitis, Ectopic, Intestinal Obstruction.

• Blood Stained Vaginal Discharge

• Leucorrhea

• Post Coital Bleeding

• Dyspareunia


13

Diagnosis

• Age/ Parity/ suggestive Symptoms

• Fever

• Pain, distension

• Past, Family H/O


14

• G.E: Poorly built/nourish, anemia, evidence of TB in lungs, LNs

• PA: ‘N’, Tender mass, doughy feel, ascitis

• PV: ‘N’, Thickened tubes, TO mass, RV fix Ut,

• PR

• PS

• Local exam.


15

Imaging Modalities


16

X - Ray

• Though it’s secondary , but 75 % cases CXR – Normal .

• May show old healed lesion in lungs.

• X – ray Spine is also important for Tb Spine.

• More Confirmatory - HSG


17

Tubal changes HSG • Non specific findings like hydrosalpinx • Multiple constrictions giving a beaded appearance • Occlusion either at the isthmus or ampulla • Pipestem appearance • Cobblestone appearance • Leopard skin appearance • Tubal calcifications • Golf club appearance - Bilateral distal isthmic obstruction • Peritubal adhesions • Caseous ulceration of the mucosa of the tube gives it an

irregular contour and diverticular outpouching surround the ampulla giving it a tufted appearance

• Same process in the isthmic region gives the typical appearance of Salpingitis isthmica nodosa (SIN).


18

Uterine changes on HSG • Endometritis, Intrauterine adhesions and asymmetrical

cavity- All non specific. • Collar-stud abscess- Specific • Tuberculosis T-shaped uterus • Pseudounicornuate uterus- Unilateral obliteration

followed by unilateral scar in uterine cavity • Small uterine cavity with irregular contour and resembling

septate appearance • Complete obstruction of uterine cavity with glove’s finger

appearance • Due to progressive endometrial lesion contrast medium

may passed through lymphatic and venous systems- Dye extravasation to vascular channels

• Pelvic node calcification also may be detected


19

Pipe stem appearance Septate appearance with small cavity

Salpingitis isthmica nodosa

Golf club appearance Glove’s finger appearance Dye extravasation to vessels


20

USG

• Adnexal mass in an adolescent girl (Not sexually active) especially with ascitis

• Small uterus

• Atrophic endometrium/ calcifications in the endometrium

• Encysted ascitis

• Saline salpingogram/ sonohysterogram showing adhesions, tubal block etc.,


21

CT and MRI and PET scan

• Peritoneal tuberculosis and tubo-ovarian lesions have usually minimal findings at CT and frequently misdiagnosed with peritoneal carcinomatosis.

• MRI is useful for the diagnosis of tubo-ovarian lesions.

• Regular pattern of small nodularities along the peritoneum at MRI are helpful findings.


22

Remember

• In spite of significant technological advances in imaging noted with ultrasonography, CT and MRI;

HSG remains the gold standard in evaluating the internal architecture of the female genital tract and fallopian

tubes.


23

Laparoscopy Findings • Tubercles on the peritoneal surface

• Inflamed or blue-coloured uterus

• Salpingitis, oophoritis or a tubo-ovarian mass

• Tubal occlusion with hydrosalpinx

• Dye dripping (instead of free flowing) from the fimbreal opening on chromopertubation

• Free peritoneal fluid looking like blood

• Caseation in the Pouch of Douglas

• “Frozen pelvis”

• Omental adhesions

24-Dec-17


24

Right upper quadrant showing dense adhesions of the liver to the anterior abdominal wall (Fitz-Hugh-Cutis syndrome )


25

Hysteroscopy Pictures


26

Laboratory Investigations

• CBC & ESR

• Sputum, Urine & G .I Aspirate

• Endometrial biopsy or curettage- detects latent endometrial T.B. Premenstrual phase • Biopsy - Cornual regions show tubercle follicles.

Pseudopregnancy with progesterone ,cyclical shedding prevented –

biopsy then show tubercles (KISTNER METHOD).

‘‘Absence of signs of T.B endometritis in any

one biopsy is not proof of absence of disease”


27

Contd..

• Bacteriological examination- Material- uterine secretions , endometrial biopsy

direct smears-Z N staining Pap Fluorescein staining

• Guinea pig inoculation - Best Confirmatory results are with endocervical

secretions

• Culture of menstrual discharge & Cervical mucus - D2 of menses collected in isotonic saline & cultured in Loewenstein’s or Petragnani’medium

• Tuberculin Skin Test- indicates presence of prior infection. + ve results in 90% of cases.


28

CURRENT TRENDS

SCREENING TESTS -

• ADA [ adenine deaminase activity]in body fluids

• Mycobacterium IgG, IgM & IgA antibodies.

• AFB smear by fluorescent microscopy .

• AFB by Zeihl Neilsen stain, Auramine Rhodamine

stain

CONFIRMATORY TESTS -

• RNA detection by Improved PCR

• Radiometric culture by BACTEC. 24-Dec-17


29

CURRENT TRENDS

• PCR - Detects DNA of mycobacterium T.B.

-Useful for diagnosis paucibacillary forms of

pulmonary or extra pulmonary T.B.

• SEROLOGICAL TESTS-

• IgM & IgG ( immunoblot assay )

98% specificity 40% sensitivity.

• Elisa & sandwich Elisa technique- use of polyclonal

antibodies as primary capture antibodies.

Can detect smear -ve T.B

Rapid ,inexpensive , simple to perform.


30

CURRENT TRENDS

PCR

• Detects Live & dead bacteria

• Nucleic Acid detected: DNA

• False +ve issues encountered very often

• Testing Time : 8-12 hours

• Cannot be used as a therapy monitoring tool,

detects both live&dead bacteria

• +ve Predictive value <75% due to problems of

contamination.


31

CURRENT TRENDS contd...

RNA detection by Improved PCR

• Detects Live bacteria

• Nucleic Acid Detected: r RNA

• No false +ve issue , no contamination

• Testing time : 3 hours

• Can be used as a therapy monitoring tool,because it

detects live bacteria

• +ve Predictive value:100% 24-Dec-17


32

CURRENT TRENDS (cont) • BACTEC 460 ( Mycobacterial culture )

- A liquid media with radiometric growth detection.

- Identification of isolates by nucleic acid probes.

- time required for isolation to 2-3 wks

( routine culture -4-8 wks)

• DNA finger printing from BACTEC for diagnosis of false +ve cultures.

• Drug Susceptibility Test

-Used for pts who fail to respond to initial therapy or relapse after Rx.

-Direct testing on liquid medium ( 3 wks).


33

QuantiFERON-TB Gold QFTG

• In vitro laboratory diagnostic test • Indirect test for M. tuberculosis complex M. tuberculosis M. bovis, M. africanum, M. microti, M. Canetti infection

• Tuberculosis disease OR latent tuberculosis infection

(LTBI)- cannot distinguish between them • Intended for use in conjunction with risk assessment,

radiography, and other medical and diagnostic evaluations


34

QuantiFERON-TB Gold ( QFTG )

• Single patient visit - whole blood sample - 4 ml of heparinised whole blood

• Must be transported to lab to allow initiation of testing within 12 hours (viable lymphocytes)

• Rapid results (within 24 hours) • No booster response • No reader bias (cf Mantoux) • Not affected by prior BCG vaccination • Impaired or altered immune function • ST: 80-95% (Mantoux 75-90%) • SP: 95-100% (Mantoux 70-95%)


35

D & C

One must do a thorough curettage, including both cornual regions (common sites for TB endometritis)

Entire endometrium is collected and divided in two parts:

Half in for formalin: for histopathological examination to look for tuberculous granulomas.

Other half in saline for smear / culture / guinea pig inoculation. Smear: Ziehl Neelson stain.

In unmarried adolescent girls menstrual discharge collected within 12 hours of onset of menses can be used for culture.


36


37


38

Keystones In Management

• Sound Understanding Of Disease

• Proper Evaluation

• CAREFUL PLANNING OF Rx

• Help Of Specialists

• Counselling / Reassurance

• Dietary Modification

• Advice -Long Term Follow Up

• OPHTHALMIC EXAMINATION ( Due To ETHAMBUTOL)

Treatment of FGTB is similar to Pulmonary TB. 24-Dec-17


39

The Essential Anti Tb Drugs Recommended dose (mg/kg)

Intermittent

Essential Anti-

TB drugs Mode of

action Potency

Daily3/ wk 2/ wk

Isoniazid (H) Bactericidal High 5 10 15

Rifampicin (R) Bactericidal High 10 10 10

Pyrazinamide(Z) Bactericidal Low 25 35 50

Streptomycin (S) Bactericidal Low 15 15 15

Ethambutol (E) Bavteriostatic Low 15 30 45

Thiacetazone (T) Bacteriostatic Low 3 Not applicable


40

Drugs Used In The Treatment Of Tuberculosis Drug Daily dose (adult) Major toxicity

Isoniazid (INH) 300 mg oral Hepatitis, peripheral

neuropathy

Rifampicin 450-600 mg oral Hepatitis, flu-like syndrome,

interstitial nephritis,

thrombocytopenia (rare)

Streptomycin 0.75-19 IM Deafness, renal failure,

vestibulopathy

Pyrazinamide 1.5-29 oral Hepatitis, hyperuricaemia

Ethambutol 5mg/kg oral Optic neuritis (rare at this

dose)

PAS 12mg oral Diarrhoea, hepatitis, ,

hypersensitirity reactions

Ethionamide 19 oral Hepatitis

Cycloserine 19 oral Depression, personality

changes psychosis, seizures

Thiacetazone 150 mg oral Exfoliative dermatitis,

hepatitis

Kanamycin 19 IM Deafness, renal failure,

vestibulopathy (rare)


41

Basic Protocol

• Intensive Phase:

3-4 drugs for first 2-4 months

• Maintenance Phase:

2 drugs for 5-12 months

• Change of drugs acc. To response, severity, toxicity, sensitivity report


42

Alternative Treatment Regimens For Each Patient Treatment Category

TB treatment

category

TB pateitns Alternative TB treatment

regimens

Initial phase Continuation

phase

1 New smear positive

PTB & seriously ill

extrapulmonary or

(smear TB)

2SHRZ (EHRZ)

2SHRZ (EHRZ)

2SHRZ (EHRZ)

2E3H3R3Z3*

6HE

4HR

4 H3R3

4 H3R3*

2 Sputum smear

positive relapse

Treatment failure &

return after default

2 SHRZE/1 HRZE

2 SHRZE/1 HRZE

2S3H3R3Z3/

1 H3R3Z3E3*

5H3R3E3

5 HRE

5H3R3E3*

3 Smear negative PTB

& extra pulmonary

TB (less severe)

2HRZ or 2 H3R3Z3

2HRZ or 2H3R3Z3

2HRZ or 2H3R3Z3

2 H3R3Z3*

6HE

2HR/4H

2 H3R3/4H

4 H3R3*

4 Chronic case

(still sputum positive

after supervised

treatment)

Not applicable

(refer to special centre if second-

line drugs available)

* Directly observed treatment regimens applied in the Revised National Tuberculosis

Programme in India.


43

WHO Regimen

• Genital TB ( severe) Category-1: 2SHRZ 4H3R3

• DOT 2(EHRZ)3 4H3R3

• Category-3, Less severe: 2HRZ 2H3R3/4H

• DOT 2(HRZ)3 4H3R3


44

Drug Resistant T.B. • Usually the result of monotherapy or the negligence

of the pt

• Resistance to INH & R’cin commonest

• Chosen regime must include mixture of essential

and second line drugs

• ESSENTIAL ANTI TB DRUGS:

Streptomycin, Pyrazinamide, Ethambutol

& Thiacetazone. 24-Dec-17


45

• Role of steroids-in combination with

AKT

50mg cortisone / 5mg Prednisolone daily in

conjunction with AKT X 3-4 months particularly to

preserve tubes

Treatment of occluded tubes in T.B. Salpingitis

Transuterine insufflation of 50-100mg of

Hydrocortisone+Streptomycin(1gm).


46

Supportive Treatment General health improvement

HPD- good diet, hematinics, vitamins

Environmental improvement

Psychological support

Personal / family counseling


47

Schaefer And Sutherland Criteria For Surgical Intervention

• Persistence of adnexal mass after 4-6 months

of antibiotic therapy

• Persistent pelvic pain

• Primary unresponsiveness to akt

• Difficulty in obtaining patient cooperation for

long term therapy


48

Desiring Pregnancy ? • Tuboplasty contraindicated in badly affected tubes

• In partially occluded tubes with a past H/O of

abdominal T.B, tubal cannulation (salpingoscopy)

possible with help of Laparo-hysteroscope.

• HYSTEROSCOPIC adhesiolysis in cases of dense

uterine synechiae (after AKT completion) HRT for

2-3 cycles helps in regeneration of endometrium


49

Prevention Aim to decrease overall incidence of TB MT screening

BCG immunization

Detection of TB mothers in pregnancy & treatment

Routine health check up (schools, community)

Suspected cases - MT / X Ray chest

Early diagnosis - timely treatment

Therapeutic Trial - ?

Prevention of AIDS


50

24-Dec-17 51 Dr Shashwat Jani. +91 99099 44160.

genital tuberculosis - how to diagnose & when to treat by dr shashwat jani

Health & Medicine