Author Information
Patel Amit, Qureshi
Shabnam, Gupta AS.
(*Second Year Resident, ** Assistant Professor, ***
Professor. Department of Obstetrics and
Gynecology, Seth GS Medical College and KEM
Hospital , Mumbai , India
Abstract
Pregnancy is an immunosuppressive state in which the
immunity of the patient, especially the cell mediated immunity is suppressed to
allow implantation and development of the zygote.
With termination of pregnancy, there is a flare up of
quiescent infection so that it becomes
symptomatic. We present a case of a postabortal patient who
presented with fever and abdominal pain after check curettage done for
incomplete abortion. She was suspected to have postabortal sepsis, flare up of
pelvic inflammatory disease or genital tuberculosis. CT scan report clinched
the diagnosis of abdominal tuberculosis.
Introduction
15-20% of extra pulmonary tuberculosis is genital
tuberculosis.[1] Though not very common genital tuberculosis can
initially present after obstetric procedures like check curettage for
in complete abortion or in the puerperium. The patient
mostly comes with fever and pain in abdomen. Differentiating between
postabortal/puerperal sepsis, flare up of pelvic inflammatory disease or
genital/abdominal tuberculosis is challenging.
Case report
A 24 year old patient gravida 3, para 1 and 2 abortions
presented with complaints of abdominal pain and progressive abdominal
distention. It was precipitated after a curettage was performed in a private set
up for incomplete first trimester spontaneous abortion. Patient developed low
grade fever and abdominal pain on the second post operative day. There was no
history of vaginal discharge or burning micturition. Patient consulted multiple
private consultants prior to coming to us. She underwent multiple
investigations and received broad spectrum antibiotics but had no clinical
improvement. On admission she had abdominal pain and vomiting. She was
afebrile. She had no foul smelling vaginal discharge, urinary complaints. There
was no history of cough or previous tuberculous infection in her or in her
family. General examination parameters were normal. Her abdomen was mildly
distended and it felt doughy on palpation. Mild tenderness was elicited in the
right iliac fossa. On speculum examination cervical os was closed. No bleeding
was seen. Cervix and vagina appeared healthy. On bimanual vaginal examination
the uterus was normal in size, bilateral fornices were free and no cervical
motion tenderness could be elicited.
The results of her investigations are tabulated in the table
below. On admission with us the patient had the reports that are shown in the 1st
5 columns of the investigation chart.
Investigations Chart
2-4-14
|
3-4-14
|
8-4-14
|
11-4-13
|
17-4-14
|
21-4-14
|
|
Haemoglobin g%
|
12.3
|
12.6
|
12.7
|
12
|
10.3
|
9.0
|
Total WBC count/mm3
|
9700
|
12000
|
12600
|
11800
|
10200
|
14000
|
Platelet count lac/mm3
|
2.53
|
Adequate
|
3.10 lac
|
3.51
|
Adequate
|
4.52
|
ESR
|
2 mm at 1hr
|
|||||
HIV
|
negative
|
|||||
VDRL
|
negative
|
|||||
HbsAg
|
negative
|
negative
|
||||
Leptospirosis
|
negative
|
negative
|
||||
Dengue
|
negative
|
negative
|
||||
PS for Malarial parasite
|
negative
|
negative
|
||||
Malarial antigen test
|
negative
|
negative
|
||||
Widal
|
negative
|
|||||
Urine routine
|
WNL
|
WNL
|
WNL
|
WNL
|
||
Urine culture
|
No growth
|
|||||
Blood culture
|
No growth
|
|||||
Tb Gold
|
Negative
|
|||||
Ultrasonography (USG)
Abdomen and pelvis It showed a mild bulky
uterus, mild fluid in POD and minimal ascites.
|
||||||
CT scan of the abdomen and
the pelvis showed locculated ascites and thickening of the peritoneum, multiple
mesenteric lymph nodes with extensive stranding, and omental calcification.
These features were suggestive of peritoneal Koch’s with mesenteric
adenopathy.
|
||||||
Figure 1: CT scan shows the enlarged multiple mesenteric lymph nodes (N).
Figure 2: CT
scan shows the locculated ascites (A) and extensive mesenteric stranding (M)
CT scan was suggestive of abdominal Koch’s. The patient was
referred to a gastroenterologist who started her on category-2 AKT. She is
following up with the gastroenterologist and her symptoms have reduced.
Discussion
Pregnancy is an immunosuppressive state. This facilitates
embryonic implantation. At the end of pregnancy rapid reversal of this
immunosuppressive state occurs. This is due to reactivation of the pre-inflammatory
substances. This immunocompetent state allows rapid flaring up of those
diseases that are dependent on the immune system. Tuberculosis is one of them.
The main pathology in tuberculosis is cell mediated immunity against the
tubercular antigen, that is suppressed during pregnancy. So as soon as
pregnancy is completed latent infection activates and produce symptoms.
Lymphocyte activity reactivates within 24 hours and recovers completely within
4 weeks. In previous trials it is seen that tuberculosis becomes symptomatic
within 10 days in 76% of cases.[2] In our case activation occurred
on day 2 after abortion. The quiescent mycobacterium tuberculosis infection
flared up and the patient became symptomatic immediately. As the patient had an
early (1st trimester) pregnancy loss, probably her cell mediated
immunity suppression reverted back faster.
Conclusion
This case is presented, as tuberculosis is a very important
ailment. The clinician has to be alert to its flare up in the immediate
peripartum state as delay in diagnosis increases patient morbidity and
unnecessary use of empirical antibiotics.
References
1.
Rajamaheshwari N . Pelvic
tuberculosis. Available from: http://www.sunmed.org/pelvictb.html
2.
Cheng VC, Woo PC, Lau SK, Cheung
CH, Yung RW, Yam LY, et al. Peripartum tuberculosis as a form of
immunorestitution disease. Eur J Clin Microbiol Infect Dis 2003;22(5):313-7.
Citation
Patel A, Qureshi
S, Gupta AS.