2Dr Ajit Virkud Professor, and Head of Department, K.B.B.Hospital, Bandra, Mumbai.Consultant,Bhatia Hospital, Mumbai
3Who 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?
12AnswerIndia has the highest incidence in the world. The reported incidence in India is 2- 10% (Malkani, 1975: 9.3%, Agarwal, 1993: 2.4%).
13What is Mycobacterium tuberculosis complex? MTB complex?
14Answer 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).
15How does TB bacillus differ from other bacteria? Why does it not respond to commonly used anti-bacterial agents?
16AnswerTuberculosis 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.
17How does Tuberculosis spread? Is it a sexually transmitted disease?
18AnswerHematogenous 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 nodesAscending 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.
19On PV examination F. Tubs are palpable? What is your diagnosis?
21What is ‘frozen pelvis’? What is its differential diagnosis?
22AnswerWhen all pelvic structures are matted together and fixed with the uterus it results in frozen pelvis.DD of frozen pelvis?Florid genital tuberculosisGrade III/IV pelvic endometriosisAdvance invasive carcinoma of cervixFollowing radiotherapy for invasive carcinoma of cervix
23You are doing D & C to rule out TB endometritis. How do you obtain the endometrium and how do you send the sample?
24AnswerOne 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
25How do you obtain a sample in adolescent unmarried girls? In virginal adolescent girls with s/s of PID one must rule out Genital TB.
26AnswerIn unmarried adolescent girls menstrual discharge collected within 12 hours of onset of menses can be used for culture.
27What are the different culture media used for TB?
28Answer Various culture media used are Lowenstein Jensen medium (color malachite green),Dorset's egg, Petroff's,Tween 80, Dubois mediumColonies are cream colored, raised, coarsely granular; dry friable and rough with spreading edges suggests virulent forms.Culture report takes 3-6 weeks.
29Is Guinea pig inoculation essential for diagnosis? Can you use any other animal for testing?
30AnswerAnimal inoculation is the only investigation accepted as confirmatory evidence of TB: Smaller lab animals like mice can be used
38AnswerTobacco Pouch Appearance seen in genital TB
39What are the HSG findings suggestive of pelvic tuberculosis ?
40Answer: In F. Tubes Bilateral blocked tubes especially at cornual end Beaded appearanceIrregular shaggy outline of tubesGolf club/ sperm head appearance: small sacculation at the filling end of isthmus/ampullary portion of tubeMaltese cross appearance: in fibrotic stage-curved or straight pipe-like appearance of tubes with lack of normal tortuosityMultiple filling defects, diverticuli or extravasation in tubal wall
41Answer: In F. TubesLeopard skin appearance: the ampulla of the tube is partially filled with dye giving a speckled appearanceRosette: the distal end of the tube is filled with dye that has a rosette appearanceTobacco pouch appearanceStraight thickened, rigid “pipe stem” tubesHydrosalpinx/ pyosalpinxCalcification in tubes
42Answer: In UterusMoth-eaten appearance: irregular outline of cavity (TB endometritis)Intra-uterine adhesions (synichae)Venous/lymphatic intravasation of dye
43What is ‘Blue Uterus Sign’? What is the role of laparoscopy in diagnosis of genital TB?
44AnswerLaparoscopy should be done carefully to avoid injury to adherent bowel loops; open laparoscopy is preferred.“Blue uterus” when chromopertubation test done with methylene blueAcute salpingitis: red, swollen edematous tubesTiny tubercles 1-4 mm on surface of organs: tubes, uterusHydrosalpinx, pyosalpinxTobacco-pouch appearanceViolin string adhesionsUnilateral / bilateral TO massesStraw colored thick jelly like exudate in PODFimbrial biopsy, peritoneal fluid may be taken to confirm the diagnosis
46AnswerLoculated ascites: The presence of fine lacy strands or particulate matter in fluid is due to thin fibrin strandsBilateral or unilateral tubo-ovarian mass
47What is Mitchison & Grosset Hypothesis What was he referring to?
48Answer Group I: Fast growing, neutral pH, aerobic PYRAZINAMIDEAnswerINH, RFMSMGroup I: Fast growing, neutral pH, aerobicGroup II: Slow growing, intracellular, acidicGroup III: Slow growing, neutral pH, hypoxicDormant bacilliANTI-TB DRUGS HAVE NO ACTIONRIFAMPICINTHE BATTLE AGAINST TUBERCULOSIS CANNOT BE WON UNTIL DRUGS THAT CAN EFFECTIVELY KILL THESE DORMANT TUBERCULOUS BACILLI ARE FOUND.
49Which drugs are used in the 4 drug short course treatment? Why are these drugs used?
50Answer Drug Bactericidal activity Isoniazide Bactericidal in-vivo and in-vitroRifampicinPyrazinamideSelectively bactericidalStreptomycin
51What are the doses of these 4 drugs? Can you give these drugs twice weekly? On what basis?
52Answer Drug Dose (<50 Kg) Dose (>50 Kg) Twice wkly dose Isoniazid (Z)300 mg450mg (8-12mg / KgmgRifampicin (R)450 mg600 mg Tab.600 mgPyrazinamide (Z) *1500 mg2000 mg3000 mgEthambutol (E)1200 mg2400 mgTHE 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).
54AnswerWHO 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 yearTreat 85% of these cases successfullyTo achieve this WHO promoted a new effective TB control program based on five essential elements called the Directly Observed Treatment Short course (DOTS) strategy
55Answer: The five elements are Continued political commitment from governmentsCase detection through quality-assured bacteriologyStandardized short-course chemotherapy (mentioned in detail below) for 6-8 months involving directly observing the patientAn effective drug supply and management systemMonitoring and evaluation system for overall assessment of program performance.
56AnswerIt 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.
58AnswerPatients 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.
60AnswerResistance 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
61AnswerDrug 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.
62What are the reserve line of drugs used in treatment of TB?
63Answer Drug <50 Kg >50 Kg Thiacetazone 150 mg Ethionamide 500 mg Cyclocerine1000 mgInj. KanamycinInj. CapreomycinInj. Viomycin
64What are the newer drugs used in the treatment of drug resistant TB?
65AnswerFluoroquinolones: Ciprofloxacin (1500 mg/day), and Ofloxacin ( mg/day) for 6 monthsAnti-leprosy drugs: Clofazine ( mg/day)Beta-lactam antibiotics: amoxicillin+ clavulanic acid (Augmentin)Macrolides: azithromycin, roxithromycin, and clarithromycin
66Management of Infertility in Genital Tuberculosis?
67AnswerTubal reconstructive surgery is contraindicated because there is usually irreparable damage of tubes (cilia are destroyed)May result in reactivation and disseminationThose 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.
68What is the role of surgery in treatment of genital TB?
69AnswerOnly surgical treatment possible is extirpative surgery with bilateral salpingo-oophorectomyAnti-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 tuberculosisLarge T-O masses, pyosalpinx, pyometra or ovarian abscess in a symptomatic patient of perimenopausal age group.
70Answer Contraindications to surgery: Active tuberculosis elsewhere in bodyPlastic peritonitis or dense adhesions around pelvic organs.During surgery: do not use non-absorbable sutures because of risk of fistula / sinusVulvectomy may be required in cases of hypertrophic vulvar involvement.
71What is the prognosis in genital TB cases as regards fertility?
72AnswerPrognosis for child-bearing is very poor; almost nil if endometrium is destroyed.Only 2-5% patients will conceive20-30% will have spontaneous abortion40-50% ectopic pregnancyOnly 20% will go to full termEven 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”