Download 26 year old Indian female with infertility and pelvic pain

26 year old Indian female
with infertility and pelvic
pain
Wednesday ID case conference
David Fitzgerald, MD
March 19th, 2008
HPI
► 26
yo Indian female being evaluated for infertility
and found to have tubal scarring on
hysterosalpingogram. She presented originally to
her infertility specialist with several years of
inability to conceive and underwent initial fertility
work up.
► Was being considered for IVF when she developed
gradual onset of pelvic and abdominal pain.
Described abd/pelvic as constant and sharp. No
N/V/diarrhea. No vaginal discharge or dysuria.
► At that time denied fevers, chill, NS, wt loss or
other systemic symptoms.
PMH
► Significant
for a tuberculoma in her brain at
10 years of age.
 Presented with seizures and headaches. She
was treated with what she recalls as 2-3 months
of multiple antibiotics and repeat CT scan of her
brain showed the tuberculoma was no longer
there.
► History
of positive PPD at admission to US
Social history
► She
has been married for five years.
► Works as an independent contractor in the
information technology industry.
► She does not drink, smoke, take drugs or
use herbal medications.
► No pets
► Last travel to India 2 years ago
► Medications
► Allergy
► Prenatal
► NKDA
vitamins
ROS
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Gen: No wt loss, fevers,
chills, fatigue
HEENT – no visual
complaints, oral lesions,
dysphagia or odynophagia
Lymph – no
lymphadenopathy
CV – no CP, SOB
Pulm – no sob, cough,
hemoptysis
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GI – no N/V/diarrhea
GU – no dysuria,
hematuria, normal
menustral periods
Skin – no rash
Neuro – No HA, focal
weakness
PE
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T 98.7, Pulse 79, blood pressure
99/65, R 16, Sat 99% on RA,
weight is 54.5 kg or 120.1 lbs.
HEENT: Pupils are equal, round,
reactive to light and
accommodation. Extraocular
movements are intact. Sclerae
are anicteric. Oropharynx is
clear.
NECK: Supple.
Lymph – no cervical, SC, axillary
or inguinal LAN
HEART: Regular rate and
rhythm.
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LUNGS: Clear to auscultation.
ABDOMEN: Soft, nontender,
nondistended, no
hepatosplenomegaly, no pelvic
pain and no masses felt.
EXTREMITIES: No clubbing,
cyanosis or edema.
NEUROLOGIC: The patient is
alert and oriented x3 with a
grossly nonfocal neuro exam.
Data
► WBC
7.7
► HGB 14.3
► Plt 335
► Basic panel WNL
► LFTs WNL
► UA negative LE/Nit, no WBC or RBC
► UCX NEG
Hysterosalpingogram
Scarred
Fallopian
tube
“T-shaped”
uterus
Scarred
Fallopian
tube
Imaging
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There is a large, multicystic
mass in the pelvis which abuts
and surrounds the uterus and
abuts the dome of the bladder.
This is a multi-lobulated mass
with the largest portions of the
mass measuring up to
approximately 10 by 10.2 cm.
There are multiple defined cystic
areas within the mass. Some of
these cystic components have
thin enhancing walls.
The uterus appears
unremarkable.
The normal ovaries are not
identified.
Discussion
Further work up
► Pt
had already had an endometrial biopsy
done by fertility specialist and this revealed:
Uterus, endometrium, biopsy
- Focally necrotizing granulomatous endometritis.
- AFB and GMS stains negative for AFB and fungal organisms respectively.
- No hyperplasia or malignancy identified.
Further work up
► Had
also had repeat endometrial biopsy and
a sample of menustral blood sent for AFB
culture
 Mycobacterium tuberculosis complex
 This isolate was identified by sequencing the 16s rRNA
gene.
►ETHAMBUTOL
5.0 S
►ISONIAZID 0.1 S
►RIFAMPIN 1.0 S
►PYRAZINAMIDE 100.0 S
Female Genital tuberculosis
► Manifests
as infertility, menstrual
irregularities, and chronic pelvic or lower
abdominal pain
► Fallopian tubes are most common infected
organ followed by the endometrium (5060%), ovary (20-30%) and cervix (5-15%)
► Many pts have a history of TB elsewhere or
prior Tb treatment
Epidemiology
► Represents
most series
1-2% of all diagnosed TB cases in
 Although estimated that 5-13% of pulmonary TB
patients develop genital TB
► 5-10
percent among infertile patients worldwide
 Less than 1% in US, closer to 20% in India
► Median
age 28 (usually 20-40 years of age)
See: Namavar Jahromi,B, Parsanezhad,ME,Ghane,Ghane-Shirazi R. (2001). Female genital
tuberculosis and infertility. International Journal of Gynecology and Obstetrics (75). 269272.
Pathogenesis
► Almost
always secondary to TB elsewhere in
body
► Primary genital Tb is very rare but has been
described in partners of male patients with
genitourinary TB
Sites of female genital TB
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Fallopian Tube Tuberculosis
 Tends to be bilateral
 Tubes become congested with flimsy adhesions that then progress
to dense adhesions
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Endometrial involvement
 Is secondary to Fallopian infection
 Usually grossly normal appearing however in advanced disease may
be atrophic or have an obliterated endometrial cavity
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Ovarian
 Ovary may be surrounded by dense adhesions or may be site of
tubo-ovarian cysts or abscess
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Other
 Cervical TB as well as vaginal and vulva TB have been reported
Clinical presentation
► Infertility
–
 40-80% incidence of infertility in patients with
female genital TB
► Chronic
lower abd or pelvic pain – 20-50%
 Pain is non-characteristic, chronic, dull, with
possible episodes of acute pain
► Alterations
in menstrual pattern – 10-50%,
 amenorrhea, menorrhagia or postmenopausal
bleeding
► Comparative
presence of symptoms and
signs in groups of women suffering from
infertility and gynaecological problems.
► See
Table 1 in: Jindal, UN. An algorithmic
approach to female genital tuberculosis
causing infertility. Int J Tuberc Lung Dis.
2006 Sep;10(9):1045-50.
Diagnosis
► Female
genital Tb is a pauci-bacillary disease
► Endometrial biopsy for path and culture is most
common diagnostic tool
► Best time to perform is shortly before
menustration as lesions are likely to be close to
surface of endometrium during this phase
► Histopath positive in 50-60%
 often granulomas, and caseation necrosis
► Culture
of bxp, menustrual blood, tubal bxp
material or peritoneal fluid may all be positive
► Results
► See
of diagnostic tests for TB
Table 2 in: Jindal, UN. An algorithmic
approach to female genital tuberculosis
causing infertility. Int J Tuberc Lung Dis.
2006 Sep;10(9):1045-50.
Hysterosalpinogography
► Visualization
of uterine cavity, and fallopian
tubes by injection of radioopaque contrast
in the uterus through the cervix
► If performed during acute disease may lead
to worsening
► Multiple findings
Laparoscopy
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Findings on
laparoscopy/laparotomy in 70
Group I patients with infertility
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See Table 3 in:
Jindal, UN. An algorithmic
approach to female genital
tuberculosis causing
infertility. Int J Tuberc
Lung Dis. 2006
Sep;10(9):1045-50.
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Findings depend on the
stage of disease and
include, miliary
granulations, plaques,
adhesions, congestion
Treatment
► Medical
treatment is main mode of therapy
► Similar to treatment elsewhere in body
► Much less need for surgical intervention
► 4 drug therapy with INH, Rif, Ethambutol, PZA,
followed by 2 drug therapy
► 6 month course followed by repeat endometrial
sampling
► Results generally successful – 97% in one study
Pregnancy following Female genital
TB
► Full
term pregnancy is uncommon following
genital TB – 10%
► Pregnancy is more likely to result in ectopic
pregnancy or miscarriage
► IVF – unclear success rate but may be as
high as 20%
Infertility outcome
► Outcome
of infertility group (Group I)
following ATT and specific ART
► See
Table 5 in: Jindal, UN. An algorithmic
approach to female genital tuberculosis
causing infertility. Int J Tuberc Lung Dis.
2006 Sep;10(9):1045-50.
Search PubMed
► Female
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
Genital Tuberculosis
Case Reports
Review
Differential Diagnosis
Therapy
In order to see PubMed results, use ViewSlide Show, or
hit F5