TUBERCULOSIS OF FEMALE GENITAL TRACT
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INTRODUCTION w w w . s i m i l i m a . c o m
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M TUBERCULOSIS
Aerobic bacillus
Non-spore for for ming
Non-motile
w w w . s i m i l i m a . c o m
Generation time: 12-20 hours Culture
3-6 weeks
1-2 weeks
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SOURCE OF INFECTION
Always secondary.
Primary focus- lungs, lymph node, urinary tract, bones and joint.
Long latent period -10- 15 years .
Menarche- increased chance of genital tuberculosis.
MODE OF SPREAD
Blood spread most common -90%.
Direct spread from peritonium- bowel lesion lymphatics from mesentric nodes- 7%.
Sexually transmitted- 1%.
PATHOLOGY
Fallopian tube 90%
Uterus 60%
Ovaries 30 %
Cervix 1-2 %
Vulva and vagina 1%
FALLOPIAN TUBE TUBERCULOSIS
By blood spread Mostly bilateral endosalphingitis Tuberculous endosalphingitis Submucosal layer of ampullary part enla rged tortous Wall thickened enlarged Initially fimbrial end open Caseation in the wall of the tube pyosapinx
FALLOPIAN TUBE
Tuberculous Tuberculous exosalphingitis
Direct extension
Peritoneal surface studded with miliary tubercles
Tobacco pouch appearance-dilated distal end.
PATHOLOGY
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UTERUS
70%
Spread from tube
Cornual end
Tubercle Tubercle situated basal layer
Ashermans syndrome -Endometrial ulceration adhesion
Pyometra- caseation material collects
OVARIES
Tubercles Tubercles on the surface
Adhesion
Thickening of capsule
Caseating abcess
CERVIX
5-10%
Descending infection
Intermenstrual bleeding or post coital bleeding
Ulcer or red papillary erosion
DD ca cervix
Biopsy
VULVA&VAGINA
Rare
Shallow painful ulcer undermined edge
Hypertrophic
Diagnosis by histology
CLINICAL CLINIC AL FEATURES FEATURES
Asymptomatic 10
Infertility 35-65
Menstrual abnormalities
Menorrhagia
Amenorrhoea
Pain, dysmenorrhoea
Tender fixed adnexal mass,abdominal mass
Repeated PID
Vaginal discharge
Post coital bleeding
HYSTEROSALPINGOGRAM FINDINGS
Suspected genital TB avoid HSG
Rigid non peristaltic pipe like tube.
Beaded appearance ,calcification of tube
Bilateral cornual block
Jagged fluffiness of tubal outline
Vascular lymphatic extravasation.
Tobacco pouch appearance.
HYSTEROSALPINGOGRAM VIEW
Figure : 28-year-old woman with genital tuberculosis. 16 Hysterosalpingogram shows bilateral tubes convoluted and fixed. There is a loculated spill (small arrows) on the right side suggestive of
RADIOGRAPHIC VIEW
Fig. 6. Radiograph demonstrates lymphatic extravasation, a deformed uterine cavity, and a narrow-rigid fallopian tube with a dilated and closed fimbrial end on the right side .
Fig. 8. The entire fallopian tube appears rigid and exhibits small terminal sacculations. 17
DIAGNOSIS OF GENITAL TB
Mantoux ,ESR.
Dilatation and curettage
Cornual end
Premenstrual
HPE , BACTEC culture, PCR
Diagnostic laparoscopy
Biopsy
X-RAY chest ,sputum AFB
HIV ELISA
MANTOUX TEST Diagnostic role of a positive Mantoux (PPD) is controversial Almost 45% of infertile women with strong indirect evidence of pelvic TB, such as laparoscopic findings (thickened tubes, areas of caseation, etc) - negative Mantoux In 27 infertile women with a positive Mantoux, only 11 had clear laparoscopic findings suggestive of FGTB Mantoux test in women with laparoscopically diagnosed tuberculosis sensitivity - 55% specificity - 80%
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MICROSCOPIC APPEARANCE OF TUBERCULAR LESION
Typical granuloma formed by lymphocytes,multinucleated giant cells,epitheloid cells, Surrounding central area of caseation.
TUBERCULOUS SALPINGITIS.
Fig.. Tuberculous salpingitis. Chronic salpingitis due to tuberculosis presents the characteristic histologic features of the tuberculous granuloma: lymphocytes, epithelioid cell granulomata, and giant cells of both the Langerhans and the foreign body type are seen. Tuberculous infection of the fallopian tube often results in an “adenomatous” proliferation of the lining epithelium. This is seen on the left of
Fig Tuberculous salpingitis may contain Schaumann bodies, which are more characteristic of sarcoidosis than tuberculosis. These are conchoidal, laminated, calcified structures, usually surrounded by foreign body 21 giant cells. (×100.).
TUBERCULOUS ENDOMETRITIS
Fig. 4. Tuberculous endometritis. Photomicrograph of a single tuberculous granuloma is seen on the left, consisting of central epithelioid cells, with a Langerhans-type giant cell surrounded by a cuff of lymphocytes. No central caseation is present. The surrounding endometrium appears completely normal; the glands are proliferative, and there is no infiltrate in the stroma,
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DIFFERENTIAL DIAGNOSIS
Ovarian cyst
Pelvic inflammatory disease
Ectopic pregnancy
Carcinoma cervix
Elephantiasis vulva
Pregnancy
TREATMENT OF GENITAL TB CHEMOTHERAPY WITH ATT ATT INITIAL PHASE 2 MONTHS
Isoniazid 5mg/kg Rifampicin 10mg/kg Pyrazinamide 25mg/kg Ethambutal 15mg/kg
CONTINUATION PHASE 4 MONTHS
Rifampicin and INH biweekly Resistant cases with HIV -1 year
TREATMENT OF GENITAL TB
Patient considered cured if 2 histological and bacteriological reports are negative.
DRUGS USED IN RESISTANT CASES
Capreomycin
Kanamycin
Ethionamide
Para-amino salicylic acid
cycloserine
SURGICAL SURGI CAL TREATMENT TREATMENT INDICATIONS
Progression of disease
Persistent active lesion
Pyosalpinx
Pyometra
Persistence of symptoms
Persistence of fistula
Surgery followed by full course chemotherapy chemotherapy..
SURGICAL SURGIC AL TREATMENT TREATMENT
Totalhysterectomy oopherectomy
Vulvectomy.
with
bilateral
TUBOPLASTY IS CONTRAINDICATED
Reactivation
Fertility cannot be restored
ART- IVF
salpingo
PROGNOSIS
CURE RATE 90%
FERTILITY 10%
TUBAL PREGNANCY VERY HIGH
ABORTION ALSO OCCUR
ONLY 2 PERCENT HAVE LIVE BIRTHS
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