Female Genital Tuberculosis: An unusual presentation

Author Information

Chawla LJ*, Mirchandani A**, Mayadeo NM***, Chakre S**.

(* 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

A 26 years old, unmarried female presented with a complaint of sudden onset, acute abdominal pain associated with severe nausea. She had regular menstrual cycles and gave no history of sexual contact. She had no preceding complaints and was apparently asymptomatic prior to this episode. Her only significant past history was that of pulmonary tuberculosis, diagnosed 3 years back, for which she had taken AKT for 6 months. She also underwent appendicectomy 2 months back. On examination, moderate pallor was present and pulse was 96/min. The other vital parameters were normal. On per abdomen examination, tenderness and guarding were noted over the entire abdomen with moderate ascites. Pelvic ultrasound (USG) revealed a heterogeneous, predominantly hypoechoeic 6.1x 4.5x 5.2 cm right sided ovarian cyst with peripheral vascularity, suggestive of a hemorrhagic cyst. Minimal free fluid was seen  in the pouch of Douglas with internal echoes suggesting pelvic hematoma and hemoperitoneum.Tumor markers (CA 125, CEA, β-HCG, AFP) were within normal limits. Magnetic resonance imaging (MRI) showed a right adnexal hematoma with adjacent intramuscular extension due to a ruptured hemorrhagic cyst or ruptured ectopic gestation. There was no evidence of a gestational sac. Urgent exploratory laparotomy was done which revealed foul smelling pyoperitoneum. Around one liter pus was drained and pus sample was sent for microbiologic study. The uterus was normal size; both fallopian tubes were hyperemic and edematous and separate from the ovaries (figure 1).

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 Douglas. No apparent pelvic cause of pyoperitoneum was seen. Surgical opinion was taken and bowel tracing was done to determine its source. Bowel exploration was negative. Right ovarian cyst wall was punctured and it drained pus, hence ovarian cystectomy was done and the cyst wall was sent for histopathological examination. In the postoperative period, the patient was started on broad spectrum antibiotics. She developed paralytic ileus on day 3 which was managed conservatively. Histopathology report showed granulomatous necrosis with neutrophilic infiltrate suggestive of tuberculous abscess with secondary infection. Pus culture grew Escherichia coli in significant number which was sensitive to piperacillin and tazobactum. After diagnosis of TB on histopathology report, chest medicine opinion was taken. A high resolution computed tomography (CT) of the chest was done which was suggestive of reactivation of old tubercular pulmonary focus. Category 2 AKT was started and patient had a speedy recovery.

Discussion

In India, genital TB is found in 0.75 to 1% of all gynecological admissions. Although genital TB can occur in any age group, the majority of the patients are in the reproductive age group, 75% being in the 20–45 years age bracket, like our patient who was 26 years old. Postmenopausal women account for 7–11% of cases of genital TB.^[2]

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.

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.

Citation

Chawla LJ, Mirchandani A, Mayadeo NM, Chakre S. Female Genital Tuberculosis: An unusual presentation. JPGO 2015. Volume 2 No. 1. Available from: http://www.jpgo.org/2015/01/female-genital-tuberculosis-unusual.html