1. Genital Tuberculosis

2. Dr Ajit Virkud Professor, and Head of Department,
K.B.B.Hospital, Bandra, Mumbai.
Consultant,
Bhatia Hospital, Mumbai

3. Who said this? What was he referring to?
“THERE IS A DREAD DISEASE…….. IN WHICH LIFE AND DEATH ARE SO STRONGLY BLENDED THAT DEATH TAKES THE GLOW AND HUE OF LIFE, AND LIFE THE GAUNT AND GRISLY FORM OF DEATH.”
What was he referring to?

4. Answer
Charles Dickens referring to Tuberculosis

5. Who discovered the Tubercle Bacillus?

6. Answer Robert Koch discovered the tubercle bacilli in 1882.
The word tuberculosis was first used in 1834.

7. What was this disease called in ancient Indian Vedas?

8. Answer
Tuberculosis was known as Raksyasman - king of diseases, in the ancient Indian Vedas

9. Who described the first case of genital TB?
Who described the first case of TB endometritis?

10. Answer
First recorded case of genital tuberculosis was described by Morgagni in 1744
First case of tubercular endometritis was reported by Kiwsch in 1847.

11. Which country has the highest incidence of TB?

12. Answer
India has the highest incidence in the world. The reported incidence in India is 2- 10% (Malkani, 1975: 9.3%, Agarwal, 1993: 2.4%).

13. What is Mycobacterium tuberculosis complex?
MTB complex?

14. Answer It comprises M. tuberculosis hominis M. bovis
M. africanum (atypical Mycobacteria spp.)
Tuberculosis in humans is mainly caused by bacteria called M. tuberculosis hominis (occasionally mycobacterium bovis or atypical tuberculosis organisms are also found).

15. How does TB bacillus differ from other bacteria?
Why does it not respond to commonly used anti-bacterial agents?

16. Answer
Tuberculosis organism is a non-motile obligate aerobe with replicating cycle of hours (slow growing)
It does not have a capsule.
It has a property of being acid-fast due to the surface lipids. This property makes it resistant to common antibacterial agents and lytic enzymes.

17. How does Tuberculosis spread?
Is it a sexually transmitted disease?

18. Answer
Hematogenous spread: according to Magnus Hames this is the commonest mode of spread seen in 90% of cases.
Descending infection (7%): direct or lymphatic spread from the peritoneum, bowel or mesenteric lymph nodes
Ascending infection: rarely (1-2% cases) infection occurs from coitus with a male suffering from urogenital tuberculosis or by use of infected sputum as a lubricant for intercourse or in children who sit naked on infected sputum.

19. On PV examination F. Tubs are palpable?
What is your diagnosis?

20. Answer
Thickened, palpable fallopian tubes suggests tubercular salpingitis.

21. What is ‘frozen pelvis’?
What is its differential diagnosis?

22. Answer
When all pelvic structures are matted together and fixed with the uterus it results in frozen pelvis.
DD of frozen pelvis?
Florid genital tuberculosis
Grade III/IV pelvic endometriosis
Advance invasive carcinoma of cervix
Following radiotherapy for invasive carcinoma of cervix

23. You are doing D & C to rule out TB endometritis.
How do you obtain the endometrium and how do you send the sample?

24. Answer
One must do a thorough curettage, including bothy 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

25. How do you obtain a sample in adolescent unmarried girls?
In virginal adolescent girls with s/s of PID one must rule out Genital TB.

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

27. What are the different culture media used for TB?

28. Answer Various culture media used are
Lowenstein Jensen medium (color malachite green),
Dorset's egg, Petroff's,
Tween 80, Dubois medium
Colonies are cream colored, raised, coarsely granular; dry friable and rough with spreading edges suggests virulent forms.
Culture report takes 3-6 weeks.

29. Is Guinea pig inoculation essential for diagnosis?
Can you use any other animal for testing?

30. Answer
Animal inoculation is the only investigation accepted as confirmatory evidence of TB: Smaller lab animals like mice can be used

31. Read this HSG
What is your diagnosis?

32. Answer
HSG showing ‘sperm head’ appearance suggesting TB salpingitis.

33. Read this hsg?
What is your diagnosis?

34. Answer
Moth eaten appearance suggestive of TB endometritis

35. Read this HSG?
What is your diagnosis?

36. Answer Venous & Lymphatic Intravasation DD Genital TB False passage
Hsg done during or just after menses
Injection of dye in a patient with bilateral cornual block

37. Read this HSG?
What is your diagnosis?

38. Answer
Tobacco Pouch Appearance seen in genital TB

39. What are the HSG findings suggestive of pelvic tuberculosis ?

40. Answer: In F. Tubes Bilateral blocked tubes especially at cornual end
Beaded appearance
Irregular shaggy outline of tubes
Golf club/ sperm head appearance: small sacculation at the filling end of isthmus/ampullary portion of tube
Maltese cross appearance: in fibrotic stage-curved or straight pipe-like appearance of tubes with lack of normal tortuosity
Multiple filling defects, diverticuli or extravasation in tubal wall

41. Answer: In F. Tubes
Leopard skin appearance: the ampulla of the tube is partially filled with dye giving a speckled appearance
Rosette: the distal end of the tube is filled with dye that has a rosette appearance
Tobacco pouch appearance
Straight thickened, rigid “pipe stem” tubes
Hydrosalpinx/ pyosalpinx
Calcification in tubes

42. Answer: In Uterus
Moth-eaten appearance: irregular outline of cavity (TB endometritis)
Intra-uterine adhesions (synichae)
Venous/lymphatic intravasation of dye

43. What is ‘Blue Uterus Sign’?
What is the role of laparoscopy in diagnosis of genital TB?

44. Answer
Laparoscopy should be done carefully to avoid injury to adherent bowel loops; open laparoscopy is preferred.
“Blue uterus” when chromopertubation test done with methylene blue
Acute salpingitis: red, swollen edematous tubes
Tiny tubercles 1-4 mm on surface of organs: tubes, uterus
Hydrosalpinx, pyosalpinx
Tobacco-pouch appearance
Violin string adhesions
Unilateral / bilateral TO masses
Straw colored thick jelly like exudate in POD
Fimbrial biopsy, peritoneal fluid may be taken to confirm the diagnosis

45. What are the usg findings suggestive of TB?

46. Answer
Loculated ascites: The presence of fine lacy strands or particulate matter in fluid is due to thin fibrin strands
Bilateral or unilateral tubo-ovarian mass

47. What is Mitchison & Grosset Hypothesis
What was he referring to?

48. Answer Group I: Fast growing, neutral pH, aerobic
PYRAZINAMIDE
Answer
INH, RFMSM
Group I: Fast growing, neutral pH, aerobic
Group II: Slow growing, intracellular, acidic
Group III: Slow growing, neutral pH, hypoxic
Dormant bacilli
ANTI-TB DRUGS HAVE NO ACTION
RIFAMPICIN
THE BATTLE AGAINST TUBERCULOSIS CANNOT BE WON UNTIL DRUGS THAT CAN EFFECTIVELY KILL THESE DORMANT TUBERCULOUS BACILLI ARE FOUND.

49. Which drugs are used in the 4 drug short course treatment?
Why are these drugs used?

50. Answer Drug Bactericidal activity Isoniazide
Bactericidal in-vivo and in-vitro
Rifampicin
Pyrazinamide
Selectively bactericidal
Streptomycin

51. What are the doses of these 4 drugs?
Can you give these drugs twice weekly? On what basis?

52. Answer Drug Dose (<50 Kg) Dose (>50 Kg) Twice wkly dose
Isoniazid (Z)
300 mg
450mg (8-12mg / Kg mg
Rifampicin (R)
450 mg
600 mg Tab.
600 mg
Pyrazinamide (Z) *
1500 mg
2000 mg
3000 mg
Ethambutol (E)
1200 mg
2400 mg
THE REASON WHY ANTI-TUBERCULOUS DRUGS CAN BE EFFECTIVELY GIVEN IN TWICE WEEKLY DOSES ALSO IS BECAUSE M. TUBERCULOSIS IS A SLOW GROWING ORGANISM (REPLICATING CYCLE OF HOURS).

53. What is DOTS?

54. Answer
WHO declared tuberculosis a global emergency in World health assembly (WHA) set two targets for TB control to be reached by 2000:
Detection of 70% of all new sputum-smear positive cases arising each year
Treat 85% of these cases successfully
To achieve this WHO promoted a new effective TB control program based on five essential elements called the Directly Observed Treatment Short course (DOTS) strategy

55. Answer: The five elements are
Continued political commitment from governments
Case detection through quality-assured bacteriology
Standardized short-course chemotherapy (mentioned in detail below) for 6-8 months involving directly observing the patient
An effective drug supply and management system
Monitoring and evaluation system for overall assessment of program performance.

56. Answer
It is defined as supervised intake of drugs five times a week for 8 weeks (in India, the patient is observed to take the drug daily in the intensive phase) and then three times a week for 4 months.
The patients are given fixed drug combipack.
The observer should be accessible, acceptable and accountable.

57. What is DOTS plus strategy?

58. Answer
Patients who have a relapse or failure are categorized into WHO category II.
In the initial phase they are given intramuscular injections of streptomycin thrice weekly for two months along with four drugs of category I (RHZE) under direct supervision. This is followed by four drugs (RHZE) thrice a week for another month. In the continuation phase they are given three drugs (RHE) thrice a week for 5 more months under direct observation.

59. What is MDR & XDR TB?

60. Answer
Resistance to one drug e.g. rifampicin or isoniazid is called drug resistant tuberculosis. Resistance to both main anti-tuberculous drugs is called ‘multi-drug resistance’ (MDR) whereas resistance to many drugs namely isoniazid, rifampicin, injectable amino- glycosides and fluroquinolones is called ‘extreme drug resistance’ (XDR).
Drug resistant tuberculosis is treated as category IV with a DOTS Plus strategy

61. Answer
Drug resistant tuberculosis is treated as category IV with a DOTS Plus strategy: comprising six second line drugs daily for six months followed by four drugs for the next 18 months in the continuation phase.

62. What are the reserve line of drugs used in treatment of TB?

63. Answer Drug <50 Kg >50 Kg Thiacetazone 150 mg Ethionamide 500 mg
Cyclocerine
1000 mg
Inj. Kanamycin
Inj. Capreomycin
Inj. Viomycin

64. What are the newer drugs used in the treatment of drug resistant TB?

65. Answer
Fluoroquinolones: Ciprofloxacin (1500 mg/day), and Ofloxacin ( mg/day) for 6 months
Anti-leprosy drugs: Clofazine ( mg/day)
Beta-lactam antibiotics: amoxicillin+ clavulanic acid (Augmentin)
Macrolides: azithromycin, roxithromycin, and clarithromycin

66. Management of Infertility in Genital Tuberculosis?

67. Answer
Tubal reconstructive surgery is contraindicated because there is usually irreparable damage of tubes (cilia are destroyed)
May result in reactivation and dissemination
Those with infertility must be treated with medical treatment; and if this does not help artificial reproductive techniques may be considered. However one must remember that in the presence of TB endometritis, the results of embryo transfer are disappointing.

68. What is the role of surgery in treatment of genital TB?

69. Answer
Only surgical treatment possible is extirpative surgery with bilateral salpingo-oophorectomy
Anti-TB chemotherpy started 2 weeks prior and continued for 6 months post-operatively.
Indications for TAH with BSO are:
Failure of medical line of treatment progression or persistence of active tuberculosis
Large T-O masses, pyosalpinx, pyometra or ovarian abscess in a symptomatic patient of perimenopausal age group.

70. Answer Contraindications to surgery:
Active tuberculosis elsewhere in body
Plastic peritonitis or dense adhesions around pelvic organs.
During surgery: do not use non-absorbable sutures because of risk of fistula / sinus
Vulvectomy may be required in cases of hypertrophic vulvar involvement.

71. What is the prognosis in genital TB cases as regards fertility?

72. Answer
Prognosis for child-bearing is very poor; almost nil if endometrium is destroyed.
Only 2-5% patients will conceive
20-30% will have spontaneous abortion
40-50% ectopic pregnancy
Only 20% will go to full term
Even after ART, the prognosis is poor especially if endometrium is destroyed

73. “ Tuberculosis Minded”
If mankind is to win the war against tuberculous organism, it is imperative that world bodies like WHO, Stop TB Organization and TB Alliance should work together to develop new and effective anti-tuberculous drugs and vaccines.
“ Tuberculosis Minded”

74. Thank You!