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Journal clubJournal club

Vichaiyut HospitalVichaiyut HospitalObstetrics and GynecologyObstetrics and Gynecology

April 2010April 2010

Viriya Lekprasert,obgyn,18745

Female genital Female genital tuberculosistuberculosis

Review from Review from www.rcog.org.ukwww.rcog.org.uk

2005 ; 7 : 75 – 792005 ; 7 : 75 – 79

David K Gatongi , et al . , UKDavid K Gatongi , et al . , UK


http://www.rcog.org.uk/

TB exists in two forms : TB exists in two forms : pulmonarypulmonary and and extrapulmonary.extrapulmonary. ( extra. is 40% of all ( extra. is 40% of all TB )TB )

Genital TBGenital TB represents 15 – represents 15 – 20 % of 20 % of extrapulmonary TBextrapulmonary TB

Affect 1.5 / 100,000 inhabitants in the Affect 1.5 / 100,000 inhabitants in the UKUK


Mycobacterium tuberculosisMycobacterium tuberculosis accounts for 90 – 95 % of accounts for 90 – 95 % of genital TB.genital TB.

M. M. bovisbovis , 5 – 10 % , 5 – 10 % ( from GI ( from GI tract )tract )


How to reach genital tract

• TB reach genital tract by 3 routes : 1. hematogenous 2. direct spread 3. primary infection


Hematogenous spreadHematogenous spread

About 90 % of casesAbout 90 % of cases

Primary focus being the lung ,Primary focus being the lung ,

lymph nodes , skeleton systemlymph nodes , skeleton system


Descending direct spreadDescending direct spread

Via the lymphatic systemVia the lymphatic system

or directly from GI tract , or directly from GI tract , mesenteric nodes ,mesenteric nodes ,

or the peritoneumor the peritoneum


Primary infectionPrimary infection

from sexual intercourse , ascending from sexual intercourse , ascending spread from vulva , vagina ( 1 % ) , spread from vulva , vagina ( 1 % ) , cervix ( 5 – 15 % ) to upper tractcervix ( 5 – 15 % ) to upper tract

Fallopian tubes 95 – 100 %Fallopian tubes 95 – 100 % Endometrium 50 – 60 %Endometrium 50 – 60 % Ovaries 20 – 30 %Ovaries 20 – 30 % Myometrium 2.5 %Myometrium 2.5 %


Presenting SYMPTOMS

• Infertility• Oligomenorrhrea• Amenorrhea• Menorrhagia• Abdominal pain• Dyspareunia• dysmenorrhea


DiagnosisDiagnosis

• Should be considered in high risk

1. unexplained infertility 2. unexplained amenorrhea 3. pelvic infection not respond to treatment 4. postmenopausal bleeding , leukorrhea ,

pyometra excluded neoplasia


Investigation

Tuberculin test in genital tuberculosis

sensitivity of 50 %

specificity of 80 %

false negative 20 %

* HIV infection and corticosteroid therapy may cause false positive


InvestigationInvestigation ( cont. )( cont. )

Chest X-rayChest X-ray is aimed at is aimed at demonstrating lesion in the lungs , demonstrating lesion in the lungs , however , however , most CXRs are normalmost CXRs are normal

Specimens / tissueSpecimens / tissue for culture or for culture or histology : endometrial tissue , histology : endometrial tissue , menstrual fluid , lesion on tubes - menstrual fluid , lesion on tubes - ovaries - adnexae ovaries - adnexae


Investigation ( cont. )Investigation ( cont. )

Rapid nucleic acid amplification techniquesRapid nucleic acid amplification techniques

: PCR , can detect fewer than 10 organisms , : PCR , can detect fewer than 10 organisms , compared with 10,000 necessary for smear .compared with 10,000 necessary for smear .

: sensitivity 85 - 95 %: sensitivity 85 - 95 %


Imaging

USG , CT , MRI are employed in

circumstances where mass is present and

useful in the presence of ascites .


Imaging Imaging ( cont. )( cont. )

• HSGHSG is performed frequently for is performed frequently for infertilityinfertility

, , should not be performed where should not be performed where TBTB is is

diagnoseddiagnosed by other means by other means , it may , it may

dissemination and flare-up of dissemination and flare-up of disease.disease.


TreatmentTreatment

• 6 months regimens including 4 drugs in the initial phase ( first 2 months )

- rifampicin

- isoniazid

- pyrazinamide

- ethambutol

followed by rifampicin and isoniazid


Side effect of anti-TB drugsSide effect of anti-TB drugs

IsoniazidIsoniazid and and rifampicinrifampicin both are both are

associated with hepatitis , cutaneousassociated with hepatitis , cutaneous

hypersensitivity and hemolytic hypersensitivity and hemolytic anemiaanemia

Isoniazid Isoniazid may cause peripheral may cause peripheral

neuropathyneuropathy


Side effect ( cont. )Side effect ( cont. )

PyrazinamidePyrazinamide causes anorexia , nausea , causes anorexia , nausea , hepatitis , arthralgia and hyperuricaemiahepatitis , arthralgia and hyperuricaemia

EthambutolEthambutol is associated with retrobulbar is associated with retrobulbar neuritis , hepatitis and peripheral neuropathyneuritis , hepatitis and peripheral neuropathy


After treatmentAfter treatment

Relapse is seen in Relapse is seen in 0-3 %0-3 % Conception rate Conception rate 19 %19 % Live birth rate Live birth rate 7.2 %7.2 % Increase in Increase in ectopic pregnancyectopic pregnancy

and and miscarriagemiscarriage rate rate


Tuberculin test (PPD test)Tuberculin test (PPD test)( review from Wikipedia )( review from Wikipedia )

20092009 , , American Thoracic SocietyAmerican Thoracic Society , , Center Disease Control and preventionCenter Disease Control and prevention : :

- - conversion testconversion test is defined as is defined as “positive” within a 2-year period “positive” within a 2-year period

- ppd test is not contraindicated - ppd test is not contraindicated for for BCG-vaccinated personsBCG-vaccinated persons and and prior BCG vaccination prior BCG vaccination


PPd testPPd test ( cont.) ( cont.)

20092009 , , US guidelinesUS guidelines : latent TB : latent TB diagnosis and treatment is considered for diagnosis and treatment is considered for BCG vaccinated personBCG vaccinated person whose ppd test whose ppd test positivepositive

If the If the first test is negativefirst test is negative, give second , give second test test 1 – 3 wk. after first injection1 – 3 wk. after first injection


PPD testPPD test (cont.) (cont.)

September 28, 2008September 28, 2008,, Centers for Centers for Disease Control and PreventionDisease Control and Prevention ( NY ( NY Times Health )Times Health )

“ “ pastpast BCG BCG vaccination should vaccination should not not chage the PPD resultchage the PPD result when the test is when the test is done done 15 years after the vaccination15 years after the vaccination “ “


Incidence of FGTBIncidence of FGTB

• 2005,2005, UKUK 0.0015 %0.0015 %

• 20032003, Dpt. Ob.-Gyn., Maulana Azad , Dpt. Ob.-Gyn., Maulana Azad Medical College, IndiaMedical College, India 0.75 – 1 %. 0.75 – 1 %. ( 2008, prevalence 1-19 % )( 2008, prevalence 1-19 % )

• 2002,2002, Dpt. Ob.-Gyn., University Malaya Dpt. Ob.-Gyn., University Malaya Medical Center, MalaysiaMedical Center, Malaysia 0.03 %0.03 %


Incidence of FGTBIncidence of FGTB (cont.)(cont.)

• 1999,1999, NY Methodist HospitalNY Methodist Hospital 0.02 %0.02 %

• 1993,1993, Dpt. Ob.-Gyn., Kwong Wah Dpt. Ob.-Gyn., Kwong Wah Hospital , HKHospital , HK 0.06 %0.06 %

• 1980,1980, Swedish HospitalSwedish Hospital 0.02-0.05 %0.02-0.05 %


• J Med Assoc Thai January 1999,

Ramathibodi Hospital , reported incidence

FGTB 0.01 % of OPD cases , 0.05 % of

IPD cases


• From January 2003 to January 2007,

12,497 cases of my gynecological patients,

8 pt., high suspicion clinical FGTB, 0.06 %


High suspicion clinical FGTB

Case 1 : Thai female, 33 yr., G1P0A1 : multiple,recurrent PID : ppd test pos., 01 May 2003 : CXR negative : counselling for anti-TB drugs



Case 2 : Th.female, 36yr., G1P0A1

contact pulmonary TB,

multiple recurrent batholinitis and abcess,

ppd test 24 Sep 2004 neg.

(prior neg. 21 MAY 1997)



Case 2 (cont.) : 29 Sep 2005, abortion

8 Nov 2005, bilat. Batholin abcess, ppd test pos.

20 Jun 2006, pt. requested repeat ppd test, NEGATIVE


High suspicion clinical FGTBHigh suspicion clinical FGTB

Case 3Case 3 : Th.female, 26yr., chronic : Th.female, 26yr., chronic pelvic pain, underlying endometriosispelvic pain, underlying endometriosis

Constitutional symptoms : lethargy, Constitutional symptoms : lethargy, weight lossweight loss

Prior ppd, 2004, neg.Prior ppd, 2004, neg. 13 Dec 2005, 13 Dec 2005, ppd positiveppd positive



• Case 4 : Th.female, 21yr., share sexual partner

• Multiple recurrent PID, condyloma,CIN 1

• PPD positive, 28 Nov 2005



• Case 5 : Th.female, 22 yr., share sexual partner with case 4.

• Multiple recurrent PID, prior pulmonary TB 3 yr. ago, complete treatment

• 20 Dec 2005, ppd pos.



Case 6 : Th.female, 26 yr.,

recurrent PID

07 Jan 2007, ppd pos.


High suspicion clinical High suspicion clinical FGTBFGTB

Case 7Case 7 : : Th.female 30 yr., G1P1A0Th.female 30 yr., G1P1A0 Recurrent PIDRecurrent PID, , metrorrhagiametrorrhagia with pelvic with pelvic

painpain, , try pregnancytry pregnancy 16 Feb 2004, 16 Feb 2004, ppd neg.ppd neg. 12 Jan 2006, 12 Jan 2006, ppd pos.ppd pos. , Second opinion , Second opinion 17 Apr 2006, mom-in-law was pulmonary TB17 Apr 2006, mom-in-law was pulmonary TB 19 Apr 2007, revisit; 19 Apr 2007, revisit; 12 March 2008, 12 March 2008,

pregnancypregnancy



Case 8 : Th.female, 30 yr., recurrent vaginitis , PID

17 Mar 2004, ppd pos.


QuantiFERON-TB (QFT), CDC QuantiFERON-TB (QFT), CDC guidelines,guidelines, 2005 Dec.2005 Dec.

QFTQFT is indicated for diagnosing is indicated for diagnosing infectioninfection

with with M. tuberculosisM. tuberculosis

including both including both TB diseaseTB disease and and latent TBlatent TB


QFT( cont.)QFT( cont.)

Used in all circumstances in Used in all circumstances in which thewhich the ppd ppd is used. is used.

Positive QFT, interventions as a Positive QFT, interventions as a

positive ppd.positive ppd.

Specificity Specificity 97.7%,97.7%, sensitivity sensitivity 67%67%

((ppdppd:spec.80%, sens.50%):spec.80%, sens.50%) Viriya Lekprasert,obgyn,18745

High suspicion clinical FGTB High suspicion clinical FGTB with QFT positivewith QFT positive

• Th. Female, 39 yr., G1P1A0

• Recurrent vaginitis

• Ppd test positive

• QFT positive

• CXR negative


Suspicion, but ppd. Neg.Suspicion, but ppd. Neg.

• Th. Female , 23 yr.

• Recurrent PID

• Ppd test negative

• QFT negative


FINALEFINALE

• Unexplained : infertility, abnormal menstruation, pelvic pain, pelvic infection

• High suspicion clinical FGTB

• Tuberculin test, QuantiFERON-TB

• Other investigation

• “Have problem !?,

consult Internal Medicine”Viriya Lekprasert,obgyn,18745

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