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Genital Tuberculosis. Dr Ajit Virkud Professor, and Head of Department, K.B.B.Hospital, Bandra, Mumbai . Consultant, Bhatia Hospital, Mumbai. Who said this?.

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slide2
Dr Ajit Virkud
  • Professor, and Head of Department,
  • K.B.B.Hospital, Bandra, Mumbai.
  • Consultant,
  • Bhatia Hospital, Mumbai
who said this
Who said this?

“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?
answer
Answer
  • Charles Dickens referring to Tuberculosis
answer1
Answer
  • Robert Koch discovered the tubercle bacilli in 1882.
  • The word tuberculosis was first used in 1834.
answer2
Answer
  • Tuberculosis was known as Raksyasman - king of diseases, in the ancient Indian Vedas
who described the first case of genital tb
Who described the first case of genital TB?
  • Who described the first case of TB endometritis?
answer3
Answer
  • First recorded case of genital tuberculosis was described by Morgagni in 1744
  • First case of tubercular endometritis was reported by Kiwsch in 1847.
answer4
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%).
answer5
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).
how does tb bacillus differ from other bacteria
How does TB bacillus differ from other bacteria?
  • Why does it not respond to commonly used anti-bacterial agents?
answer6
Answer
  • Tuberculosis organism is a non-motile obligate aerobe with replicating cycle of 17-24 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.
how does tuberculosis spread
How does Tuberculosis spread?
  • Is it a sexually transmitted disease?
answer7
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.
answer8
Answer
  • Thickened, palpable fallopian tubes suggests tubercular salpingitis.
what is frozen pelvis
What is ‘frozen pelvis’?
  • What is its differential diagnosis?
answer9
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
you are doing d c to rule out tb endometritis
You are doing D & C to rule out TB endometritis.
  • How do you obtain the endometrium and how do you send the sample?
answer10
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
how do you obtain a sample in adolescent unmarried girls
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.
answer11
Answer
  • In unmarried adolescent girls menstrual discharge collected within 12 hours of onset of menses can be used for culture.
answer12
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.
is guinea pig inoculation essential for diagnosis
Is Guinea pig inoculation essential for diagnosis?
  • Can you use any other animal for testing?
answer13
Answer
  • Animal inoculation is the only investigation accepted as confirmatory evidence of TB: Smaller lab animals like mice can be used
read this hsg
Read this HSG
  • What is your diagnosis?
answer14
Answer
  • HSG showing ‘sperm head’ appearance suggesting TB salpingitis.
read this hsg1
Read this hsg?
  • What is your diagnosis?
answer15
Answer
  • Moth eaten appearance suggestive of TB endometritis
read this hsg2
Read this HSG?
  • What is your diagnosis?
answer16
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
read this hsg3
Read this HSG?
  • What is your diagnosis?
answer17
Answer
  • Tobacco Pouch Appearance seen in genital TB
answer in f tubes
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
answer in f tubes1
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
answer in uterus
Answer: In Uterus
  • Moth-eaten appearance: irregular outline of cavity (TB endometritis)
  • Intra-uterine adhesions (synichae)
  • Venous/lymphatic intravasation of dye
what is blue uterus sign
What is ‘Blue Uterus Sign’?
  • What is the role of laparoscopy in diagnosis of genital TB?
answer18
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
answer19
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
answer20

ANTI-TB DRUGS HAVE NO ACTION

INH, RFMSM

RIFAMPICIN

PYRAZINAMIDE

Answer

Group I: Fast growing, neutral pH, aerobic

Group II: Slow growing, intracellular, acidic

Group III: Slow growing, neutral pH, hypoxic

Dormant bacilli

THE BATTLE AGAINST TUBERCULOSIS CANNOT BE WON UNTIL DRUGS THAT CAN EFFECTIVELY KILL THESE DORMANT TUBERCULOUS BACILLI ARE FOUND.

what are the doses of these 4 drugs
What are the doses of these 4 drugs?
  • Can you give these drugs twice weekly? On what basis?
answer22
Answer

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 17-24 HOURS).

answer23
Answer
  • WHO declared tuberculosis a global emergency in 1993. 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
answer the five elements are
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.
answer24
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.
answer25
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.
answer26
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
answer27
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.
answer29
Answer
  • Fluoroquinolones: Ciprofloxacin (1500 mg/day), and Ofloxacin (400-600 mg/day) for 6 months
  • Anti-leprosy drugs: Clofazine (100-200 mg/day)
  • Beta-lactam antibiotics: amoxicillin+ clavulanic acid (Augmentin)
  • Macrolides: azithromycin, roxithromycin, and clarithromycin
answer30
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.
answer31
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.
answer32
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.
answer33
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
slide73

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”