26 year old Indian female with infertility and pelvic pain

1. 26 year old Indian female with infertility and pelvic pain Wednesday ID case conference David Fitzgerald, MD March 19th, 2008

2. 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.

3. 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

4. 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

5. Medications Prenatal vitamins Allergy NKDA

6. 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 GI – no N/V/diarrhea GU – no dysuria, hematuria, normal menustral periods Skin – no rash Neuro – No HA, focal weakness ROS

7. 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. 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. PE

8. Data • WBC 7.7 • HGB 14.3 • Plt 335 • Basic panel WNL • LFTs WNL • UA negative LE/Nit, no WBC or RBC • UCX NEG

9. Hysterosalpingogram Scarred Fallopian tube Scarred Fallopian tube “T-shaped” uterus

10. 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. Imaging

12. Discussion

13. 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.

14. 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

15. 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 (50-60%), ovary (20-30%) and cervix (5-15%) • Many pts have a history of TB elsewhere or prior Tb treatment

16. Epidemiology • Represents 1-2% of all diagnosed TB cases in most series • 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). 269-272.

17. 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

18. Sites of female genital TB • Fallopian Tube Tuberculosis • Tends to be bilateral • Tubes become congested with flimsy adhesions that then progress to dense adhesions • Endometrial involvement • Is secondary to Fallopian infection • Usually grossly normal appearing however in advanced disease may be atrophic or have an obliterated endometrial cavity • Ovarian • Ovary may be surrounded by dense adhesions or may be site of tubo-ovarian cysts or abscess • Other • Cervical TB as well as vaginal and vulva TB have been reported

19. 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

20. 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.

21. 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

22. Results of diagnostic tests for TB • See 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.

23. 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

24. Findings depend on the stage of disease and include, miliary granulations, plaques, adhesions, congestion Findings on laparoscopy/laparotomy in 70 Group I patients with infertility 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. Laparoscopy

25. 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

26. 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%

27. 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.

28. Search PubMed • Female Genital Tuberculosis • Case Reports • Review • Differential Diagnosis • Therapy In order to see PubMed results, use ViewSlide Show, or hit F5