Presentation of Tuberculosis in Gynecology

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1 International Journal of Scientific Research in Knowledge, 2(11), pp , 2014 Available online at ISSN: ; 2014; Author(s) retain the copyright of this article Full Length Research Paper Samar Dawood Y. Sarsam Assistant Professor-Al Kindy College of Medicine, University of Baghdad, Iraq; Received 09 October 2014; Accepted 20 November 2014 Abstract. Female genital tract tuberculosis is a rare disease, the exact incidence is not accurately known as it is under reported due to asymptomatic cases lack of reliable confirmatory investigations. Observational study held at Elwiya maternity teaching hospital, from the beginning of June 2012 until the beginning of October During this period, nine patients diagnosed as cases of female genital tract tuberculosis. Patients admitted as emergency or elective cases, symptoms at presentation were fever, vomiting, loss of weight, loss of appetite, mild abdominal pain, acute abdomen, abdominal mass, ascites, elevated CA-125 serum levels,, infected cesarean section wound. All these nine cases were diagnosed followed up for one year. The diagnostic dilemma arises due to varied clinical presentation so clinical suspicion detailed general physical examination should always be there especially in high prevalence areas of tuberculosis. Keywords: pulmonary tuberculosis, extra pulmonary tuberculosis, s, 1. INTRODUCTION Tuberculosis (TB) is as old as human civilization (Rao, 1981). In 2012, 8.6 million people fell ill TB 1.3 million died from TB. Over 95% of TB, deaths occur in low- middle-income countries, it is among the top three causes of death for women aged 15 to 44 (Tuberculosis Fact sheet, 2013). Tuberculosis is a preventable curable infective disease, caused mainly by Mycobacterium tuberculosis, it exists in two forms: pulmonary extra pulmonary tuberculosis (Sarawat et al., 2010). Tuberculosis is seen in all ages Mycobacterium tuberculosis is the causative organism in 90-95% of cases where as Mycobacterium bovis can also cause the disease (Duggal et al., 2009). In humans, tuberculosis can affect any organ including genital system. Manifestations include the traditional symptoms of fever, night-sweats weight-loss. There is a host of different clinical, radiological, microbiological pathological features that are used to diagnose TB. In 2009, World Health Organization (WHO) reported that there was a global reduction in the number of TB cases since 2006 (WHO, 2013). TB can affect the female genital system can cause a variety of symptoms signs, spanning from fertility problems to pregnancy complications including pregnancy losses. Genital system tuberculosis represents 15-20% of extrapulmonary TB is usually asymptomatic affecting mainly young women in the reproductive age group (Duggal et al., 2009). The exact incidence of genital tuberculosis is difficult to assess as it is not well reported like pulmonary tuberculosis many times it is asymptomatic due to not readily available laboratory test which is easy to perform reliable (Sharma, 2008). Almost invariably, tuberculosis of the female genital tract is secondary to a primary lesion elsewhere the latter is usually quiescent by the time pelvic involvement is diagnosed. Sexual transmission from a male partner is extremely rare. Another mode of involvement of ovaries, serosa uterus is peritoneal spread from an intraabdomen lesion in minority of cases. However, generally infection reaches the genital tract ( in most cases) by blood spread usually from pulmonary lesion (Malhotra, 2012). Pelvic peritonitis is present in 40-50% of cases can be executive type or adhesive type (Daftray Patki, 2009). The aim of this study is aim to demonstrate the possible different presentation of extra pulmonary tuberculosis in female genital tract. 2. PATIENTS AND METHODS Observational study held at Elwiya maternity teaching hospital, from the beginning of June 2012 until the beginning of July 2014 during this period, nine patients were diagnosed as having tuberculosis of the 517

2 Sarsam female genital tract tuberculosis peritonitis. All patients admitted as emergency or elective cases. Full history examination were. Symptoms at presentation were fever, vomiting, loss of weight, loss of appetite, mild abdominal pain, acute abdomen, abdominal mass, ascites, or out elevated serum levels CA-125, blocked by hysterosalpigography (HSG), infected cesarean section wound. Two cases (number 2 3) admitted as emergency acute abdomen, ascites s, both ended emergency laparotomy, there was severe adhesions, pus collection yellowishwhite tubercles all over the peritoneum, drainage evacuation, it revealed wet type peritoneal tuberculosis, biopsy taken revealed tous TB peritonitis. One of them was 15 years old unmarried girl. The other one had cesarean section two months before presenting to us; the indication was chorioamnitis in her 28 weeks of pregnancy, fig. 1 shows intra operative findings of case no. 2. Table 1: Demographic features Cases Age Social status high low middle low middle low low middle middle occupation urban rural urban rural urban rural rural urban urban job Health House wife student House wife House House House House worker Medical history of the patient Family history of tuberculosis worker Chest infection plural effusion four months before presentation Fever during pregnancy 2 months before presentation was diagnosed as chorioamnitis ended cesarean section -ve Chest infection 8 months before presentation. She is diabetic 518 wife wife wife wife -ve -ve -ve -ve -ve -ve +ve -ve +ve +ve -ve +ve +ve -ve Other two cases (number 1 4) admitted for abdominal pain, high ca 125 suspicion of malignancy. One had ascites so PCR for ascetic fluid revealed tuberculosis. The other patient had no ascites so laparoscopy was performed, it revealed severe adhesions the abdominal cavity was studded yellowish-white tubercles as shown in fig.2, biopsy from these tubercles revealed peritoneal tuberculosis it was dry type this lady gave history of severe chest infection plural effusion four months before presentation which was treated as severe chest infection as the PCR was negative for tuberculosis at that time. The fifth patient presented infected wound of cesarean section not responding to treatment for 14 days, the decision was to do debridement cleaning of the wound under general anesthesia, biopsy showed tous tuberculosis, The other four cases presented primary secondary, one case had only blocked by hysterosalpigography, two had amenorrhea, small s blocked one had only small blocked. For all these four cases laparoscopy, dilatation curettage revealed tuberculosis of fibro adhesive type, fig.3 shows the laparoscopic finding of case number 8, in cases amenorrhea TB endometritis was the biopsy result. All these patients

3 International Journal of Scientific Research in Knowledge, 2(11), pp , 2014 were managed at chest respiratory diseases specialized center in Baghdad, were treated for 6-9 months followed for one year. 3. RESULTS As shown in Table 1, all patients were of reproductive age, of different social status. Five patients were from rural areas, one of the patients was a health worker, two patients gave history of chest infection more than four months before presentation one had fever pregnancy diagnosed as chorioamnitis ended cesarean section. Five patients had family history of tuberculosis one discovered to be diabetic. Table 2 shows the symptoms at presentation. Three cases presented acute abdominal pain abdominal mass, two had high CA125 s four cases presented. Table 3 shows the Investigations at presentation. ESR is high in 6 cases, CA 125 is high in two cases, tuberculin test was +ve in 3 cases, ultrasound showed in seven cases, chest x ray was normal in all patients CT scan showed omental caking in one patient bilateral s. As seen in table -4 PCR was diagnostic in case number four misleading in case number one biopsy was the definite diagnosis. All patients were managed at chest respiratory diseases specialized center in Baghdad antituberculosis drugs for six to nine months were followed for one year. Those amenorrhea they responded to treatment menstruation restored in three of them one continued to have amenorrhea in spite of anti TB hormone replacement two of them regained patency of the. Those s high ca 125 the s disappeared. These results are shown in table 5. Table 2: symptoms at presentation Cases Fever -ve yes yes yes yes -ve -ve -ve -ve Vomiting -ve yes yes yes -ve -ve -ve -ve -ve Loss of appetite -ve yes yes yes yes -ve -ve -ve -ve Loss of weight yes -ve -ve yes yes -ve -ve -ve -ve Abdominal pain yes yes -ve yes yes -ve -ve -ve -ve Acute abdomen -ve yes yes yes -ve -ve -ve -ve -ve Amenorrhea -ve yes -ve -ve Yes -ve yes -ve Yes Abdominal mas -ve yes yes -ve -ve -ve -ve -ve -ve Ascites -ve yes yes yes -ve -ve -ve -ve -ve Ovarian Bilateral for three months Right Right Left -ve Left Left Bilateral s Infertility -ve -ve -ve Secondary -ve Primary Primary Secondary Primary hysterosalpigography Not Not Not Patent Not Infected cesarean section wound -ve -ve -ve -ve yes -ve -ve -ve -ve Table 3: The Investigations at presentation -ve 519

4 Sarsam Table 4: The root of diagnosing, either by biopsy or by PCR Case no diagnosis Dry TB peritonitis Biopsy from miliary nodules on the peritoneum Laparoto my Wet TB Biopsy Laparotomy Wet TB Biopsy PCR from ascetic fluid Wet TB Biopsy from the infected wound not responding to treatment Biopsy Fibro adhesive Biopsy Fibro adhesive fibroadhes ive Biopsy Result of biopsy epithelioid s central caseous necrosis granulom a histiocyte s Not non-caseating tous inflammation Table 5: The outcome of follow up Case no Outcome Ovarian s disappeared Responded to treatment Responded to treatment Got well Responded to treatment Ascites disappeared She regained tubal patency Still having amenorrhea blocked Beaded small right biopsy Undergoing In Vitro Fertilization program 4. DISCUSSION The World Bank provides data about tuberculosis in Iraq from 1990 to The average value for Iraq during that period was cases of tuberculosis per 100,000 people a minimum of 45 cases per 100,000 people in 2010 a maximum of 54 cases per 100,000 people in Doctors say TB had been largely under control in Iraq for the past 50 years but is now making a comeback due to widespread poverty, large amounts of dust in the air a lack of health awareness programs medicines. "The spread of TB after more than 50 years is something worrying," The Iraqi health system was badly affected by extended years of conflict international sanctions. Due to the absence of a national census in Iraq, estimation of national prevalence of TB cases was a significant challenge. Disease patterns have changed, a higher incidence of disseminated extra pulmonary disease now found (The World Bank, 2012; Golden Vikram, 2005). Tuberculosis annual report in Iraq 2012 republic of Iraq ministry of health chest respiratory diseases specialized center reported 9099 cases of TB in the year 2012, of these 3261 were extra pulmonary (35.82%) of all detected cases of tuberculosis. This study revealed, female genital tract tuberculosis is present it can present in different presentation as we can see in these cases, is an important presentation high CA 125 there will be suspicion of malignancy, acute abdomen abdominal mass was another presentation which ended emergency laparotomy, blocked amenorrhea were diagnosed through laparoscopy after taking biopsy. In addition one of our cases presented infected wound of cesarean section, so our advice is to do visual exploration of the abdomen during cesarean section to detect any abnormality because we had two cases one presented infected cesarean section wound the other presented acute abdomen abdominal mass two months after doing cesarean section for chorioamnitis when she was 28 weeks pregnant. It can be noticed also that in two patients out of nine, unnecessary laparotomy was which can be distressing to the patient the surgeon as well, while if tuberculosis was suspected we could have diagnosed treated it in a simple noninvasive way. Four cases presented blocked ; two of them had endometrial tuberculosis. The important issue was the variable presentation difficulty in diagnosis especially the chest x ray the ESR were normal at time of presentation in one of our patients the PCR did not detect the disease in pleural effusion. As we can see, the definite diagnosis was by biopsy which showed caseating non caseating histeocytes Langerhans. Tuberculosis in different organ systems may mimic alternate pathology so histopathological or laboratory evidence is often needed to support suspicions on imaging, before treatment is commenced (Federle et al., 2009 Dähnert, 2011). 520

5 International Journal of Scientific Research in Knowledge, 2(11), pp , 2014 TB in Iraq is still a medical social problem; we have problems in diagnosis registration of tuberculosis. Extra pulmonary tuberculosis is still a medical challenge to physicians. There is no one particular test in all cases. There are varieties of tests may be required to make the diagnosis of female genital tract tuberculosis. Clinical suspicion should always be there especially in high prevalence areas, since it is a pauci-bacillary disease so demonstration of tuberculosis is many times quite difficult. Nucleic acid amplification rapid molecular techniques using nucleic acid amplification can detect DNA in 48 hours of infection, it has a sensitivity of % specificity of 92-98% (Malhorta, 2012), but in Iraq PCR is still not properly used, regarding our patients it was diagnostic in one case in the other was misleading. Female genital tract tuberculosis is a rare disease, yet its sequel complications can have profound effects on the affected women health. Women from areas where TB is more prevalent lacks response to medication should prompt physicians to take into consideration the possibility of TB as an underlying cause of the problem (Alhakeem Schneider, 2013). 5. CONCLUSION Extra pulmonary tuberculosis is unpredictable female genital tract tuberculosis can present in unusual presentation, it is recommended that Clinical suspicion detailed general physical examination should always be there in consideration to the prevalence of tuberculosis in Iraq. REFERENCES Alhakeem M, Schneider A. (2013). Genital tuberculosis: A rare cause of vulvovaginal discharge swelling. Journal of Microbiology Infectious Diseases, 3 (3): Daftray SN, Patki A (2009). Reproductive Endocrinology : principles clinical practice. New Delhi : BI Publications, pp 450. Dähnert W (2011). Radiology Review Manual. Lippincott Williams & Wilkins, ISBN: Duggal S, Duggal N, Hans C, Mahajan RK (2009). Female genital TB HIV co-infection. Indian J. Med. Microbiol, 27: Federle MP, Jeffrey RB, Woodward PJ, Borhani A (2009). Diagnostic imaging, Abdomen. AMIRSYS Publishing, pp: Golden MP, Vikram HR (2005) Extrapulmonary Tuberculosis: An Overview. Am Fam Physician., 72 (9): The World Bank (2012). Iraq Tuberculosis: cases per 100,000 people, source: Malhotra H (2012). Genital tuberculosis. Apollo Medicine, 9(3): Rao KN (1981). History of Tuberculosis in Text book of Tuberculosis - 2nd Edition. Vikas Publishing House. Sarawat P, Swarankar ML, Bhari A, Soni R (2010). Detection of active female genital tuberculosis by molecular method. Int J Pharm Bioscience, 1(4): B-238. Sharma JB (2008) Tuberculosis Obs & Gynae. Practice, Progress in Obs Gynae, volume 18. Tuberculosis annual report in Iraq (2012) Republic of Iraq, Ministry of Health; chest respiratory diseases specialized center. Tuberculosis Fact sheet N 104 (2013). World Health Organization. Updated October. World Health Organization (WHO). Global Tuberculosis Control (2009) - Epidemiology, Strategy, Financing. who.int/tb/publications/global_report/2009/en/ index.html. 521

6 Sarsam Assistant prof. Dr. Samar Dawood Y. Sarsam was born in Baghdad (1960), got her M.B.Ch.B Degree (1984); Post graduate diploma in Obs. & Gye. (D.O.G) 1992; Board in Obs. & Gye. (C.A.B.O.G) 1992; Worked as Specialist in Mosul ( ); She joined the academic staff at University of Mosul ( ); She joined the academic staff at University of Baghdad, Al Kindey Medical College (2005 Until now) got the assistant professor degree at (2008). Areas of specialization interest: laparoscopy. 522