Author Information
Chawla LJ*, Mirchandani A**, Mayadeo
NM***
(* Senior Registrar, ** Assistant Professor, *** Professor. Department of Obstetrics
and Gynecology, Seth GS Medical College & KEM Hospital ,
Mumbai , India
Abstract
Genital tuberculosis is the most baffling of all genital
disorders, especially because of its various presentations. Usually considered
to have a chronic course, it can present as an acute emergency as in our case. Radiological
diagnosis can often be unreliable and cause diagnostic dilemmas in an atypical
clinical scenario. Our case is one such example of how a young unmarried female
with an acute abdomen and radiology suggestive of hemorrhagic ovarian cyst with
hemoperitoneum turned out to be a case of active genital tuberculosis.
Introduction
Female pelvic tuberculosis (TB) is one of the most under
diagnosed conditions in gynecology. An increase in extra pulmonary tuberculosis
is being reported in young women worldwide and is an important cause of
significant morbidity, both short and long term, especially in the reproductive
age group.[1] High risk factors include a history of previous
pulmonary TB infection, low socioeconomic background and residence in high
prevalence areas such as India, were present in our case. Immunocompromised
status as in drug abusers, HIV positive status and contact with pulmonary TB
sufferer are other risk factors.[2] High degree of suspicion, good
history taking, thorough clinical examination and judicious use of
investigations may help in early diagnosis and timely treatment preventing
infertility and other sequelae. [1]
Case Report
Figure 1: Uterus with bilateral congested fallopian tubes and right ovarian cyst that drained pus. Pus flakes are seen adherent to all the pelvic structures.
A right sided ovarian cyst 7x8 cm was seen adherent to the pouch of
Discussion
In India
Genital TB almost always
occurs secondary to pulmonary tuberculosis, commonly by the hematogenous route
in a manner similar to spread to other extrapulmonary sites. In our case of
genital TB in a young girl who was not sexually active, reactivation of
pulmonary focus of infection lead to pelvic TB. However, primary genital TB can
rarely occur by direct inoculation of tubercle bacilli over vulva or vagina
during sexual intercourse with a partner suffering from active tuberculous
lesions of genitalia.[3]
Most cases of female
genitourinary tuberculosis are difficult to ascertain as the disease may be
asymptomatic (11%).[4] Or it may masquerade as other gynecological
conditions and can go unrecognized, like in this case. The clinical presentation varies from patient
to patient, symptoms like infertility (almost in 60% cases), abdominal and
pelvic pain, menstrual disorders like scanty menstruation or amenorrhea are the
usual presentations.[5] Pelvic TB has also been reported in
literature where it has presented as an adnexal mass with raised levels of CA
125 masquerading as ovarian cancer necessitating unnecessary surgical
intervention.[6] In our case, the acute presentation of the disease
with deteriorating condition of the patient made it imperative for us to
intervene early and the in situ findings were unexpected.
The pickup rate of
tuberculosis on ultrasound is 100% for ascites / loculated fluid and 93 % for
an adnexal mass.[4] CT and MRI are also useful in the diagnosis.[1]Awareness
of these features may improve diagnostic accuracy and avoid misdiagnosis and
unnecessary surgical intervention like in this case where these features of TB
were misinterpreted as those of a hemorrhagic cyst and hemoperitoneum.
The final diagnosis in
this case was made only on the basis of histopathological examination as at laparotomy,
classical features of tubercular pelvic infection, like miliary granulomas,
tubercles over the fallopian tubes and uterus, hydrosalpinx and adhesions, were
absent.[4] As Mycobacterium tuberculosis might not be demonstrated
in every case, newer investigations like ELISA and PCR are being used. But in
our set up, their use is restricted due to high cost and nonavailability.[4]
Conclusion
Pelvic tuberculosis should always be kept in mind for the differential diagnosis of a patient with adnexal mass and ascites, especially in those at high-risk. The presence of effective antitubercular therapy significantly reduces the morbidity and mortality of the patient, but further research is required to help early establishment of diagnosis, and for interventions leading to preservation of reproductive capability of the affected individual.
Citation
Pelvic tuberculosis should always be kept in mind for the differential diagnosis of a patient with adnexal mass and ascites, especially in those at high-risk. The presence of effective antitubercular therapy significantly reduces the morbidity and mortality of the patient, but further research is required to help early establishment of diagnosis, and for interventions leading to preservation of reproductive capability of the affected individual.
References
1.
Sharma JB. “Tuberculosis in
Obstetric and Gynecological Practice”. John Studd, Seang Lin Tan, Frank A. Chervenak.
Current Progress in Obstetrics and Gynecology. TreeLife Media. Vol 1 (2012): 305-327.
2.
Arora, V. K., Gupta R, Arora R. Female
genital tuberculosis-Need for more research. Indian Journal of Tuberculosis 2003;50:9-12.
3. Gatongi DK, Gitau G, Kay V, Ngwenya
S, Lafong C, Hasan A. Female genital tuberculosis. The Obstetrician & Gynaecologist
2005;7:75-79.
4. Chhabra, S., K. Saharan, and D. Pohane.
"Pelvic Tuberculosis continues to be a disease of dilemma-Case series".
Indian Journal of Tuberculosis, 2010; Volume 57:90-94. Available from: http://medind.nic.in/ibr/t10/i2/ibrt10i2p90.pdf.
5. Qureshi RN, Samad S, Hamid R, Lakha
SF. Female genital tuberculosis revisited. JOURNAL-PAKISTAN MEDICAL ASSOCIATION,
2001;51:16-18.
6. I˙lhan AH, Durmus¸og˘lu F. Case
report of a pelvic-peritoneal tuberculosis presenting as an adnexial mass and
mimicking ovarian cancer, and a review of the literature." Infectious
diseases in obstetrics and gynecology 2004;12:87-89.
Chawla LJ, Mirchandani A, Mayadeo
NM