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Genital Tuberculosis

Genital Tuberculosis. Dr Ajit Virkud Professor, and Head of Department, K.B.B.Hospital, Bandra, Mumbai . Consultant, Bhatia Hospital, Mumbai. Who said this?.

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Genital Tuberculosis

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  1. Genital Tuberculosis

  2. Dr Ajit Virkud • Professor, and Head of Department, • K.B.B.Hospital, Bandra, Mumbai. • Consultant, • Bhatia Hospital, Mumbai

  3. Who said this? “THERE IS A DREAD DISEASE…….. IN WHICH LIFE AND DEATH ARE SO STRONGLY BLENDED THAT DEATH TAKES THE GLOW AND HUE OF LIFE, AND LIFE THE GAUNT AND GRISLY FORM OF DEATH.” • What was he referring to?

  4. Answer • Charles Dickens referring to Tuberculosis

  5. Who discovered the Tubercle Bacillus?

  6. Answer • Robert Koch discovered the tubercle bacilli in 1882. • The word tuberculosis was first used in 1834.

  7. What was this disease called in ancient Indian Vedas?

  8. Answer • Tuberculosis was known as Raksyasman - king of diseases, in the ancient Indian Vedas

  9. Who described the first case of genital TB? • Who described the first case of TB endometritis?

  10. Answer • First recorded case of genital tuberculosis was described by Morgagni in 1744 • First case of tubercular endometritis was reported by Kiwsch in 1847.

  11. Which country has the highest incidence of TB?

  12. Answer • India has the highest incidence in the world. The reported incidence in India is 2-10% (Malkani, 1975: 9.3%, Agarwal, 1993: 2.4%).

  13. What is Mycobacterium tuberculosis complex? • MTB complex?

  14. Answer • It comprises • M. tuberculosis hominis • M. bovis • M. africanum (atypical Mycobacteria spp.) • Tuberculosis in humans is mainly caused by bacteria called M. tuberculosis hominis (occasionally mycobacterium bovis or atypical tuberculosis organisms are also found).

  15. How does TB bacillus differ from other bacteria? • Why does it not respond to commonly used anti-bacterial agents?

  16. Answer • Tuberculosis organism is a non-motile obligate aerobe with replicating cycle of 17-24 hours (slow growing) • It does not have a capsule. • It has a property of being acid-fast due to the surface lipids. This property makes it resistant to common antibacterial agents and lytic enzymes.

  17. How does Tuberculosis spread? • Is it a sexually transmitted disease?

  18. Answer • Hematogenous spread: according to Magnus Hames this is the commonest mode of spread seen in 90% of cases. • Descending infection (7%): direct or lymphatic spread from the peritoneum, bowel or mesenteric lymph nodes • Ascending infection: rarely (1-2% cases) infection occurs from coitus with a male suffering from urogenital tuberculosis or by use of infected sputum as a lubricant for intercourse or in children who sit naked on infected sputum.

  19. On PV examination F. Tubs are palpable? • What is your diagnosis?

  20. Answer • Thickened, palpable fallopian tubes suggests tubercular salpingitis.

  21. What is ‘frozen pelvis’? • What is its differential diagnosis?

  22. Answer • When all pelvic structures are matted together and fixed with the uterus it results in frozen pelvis. • DD of frozen pelvis? • Florid genital tuberculosis • Grade III/IV pelvic endometriosis • Advance invasive carcinoma of cervix • Following radiotherapy for invasive carcinoma of cervix

  23. You are doing D & C to rule out TB endometritis. • How do you obtain the endometrium and how do you send the sample?

  24. Answer • One must do a thorough curettage, including bothy cornual regions (common sites for TB endometritis) • Entire endometrium is collected and divided in two parts: • Half in for formalin: for histopathological examination to look for tuberculous granulomas. • Other half in saline for smear / culture / guinea pig inoculation. Smear: Ziehl Neelson stain

  25. How do you obtain a sample in adolescent unmarried girls? • In virginal adolescent girls with s/s of PID one must rule out Genital TB.

  26. Answer • In unmarried adolescent girls menstrual discharge collected within 12 hours of onset of menses can be used for culture.

  27. What are the different culture media used for TB?

  28. Answer Various culture media used are • Lowenstein Jensen medium (color malachite green), • Dorset's egg, Petroff's, • Tween 80, Dubois medium • Colonies are cream colored, raised, coarsely granular; dry friable and rough with spreading edges suggests virulent forms. • Culture report takes 3-6 weeks.

  29. Is Guinea pig inoculation essential for diagnosis? • Can you use any other animal for testing?

  30. Answer • Animal inoculation is the only investigation accepted as confirmatory evidence of TB: Smaller lab animals like mice can be used

  31. Read this HSG • What is your diagnosis?

  32. Answer • HSG showing ‘sperm head’ appearance suggesting TB salpingitis.

  33. Read this hsg? • What is your diagnosis?

  34. Answer • Moth eaten appearance suggestive of TB endometritis

  35. Read this HSG? • What is your diagnosis?

  36. Answer • Venous & Lymphatic Intravasation • DD • Genital TB • False passage • Hsg done during or just after menses • Injection of dye in a patient with bilateral cornual block

  37. Read this HSG? • What is your diagnosis?

  38. Answer • Tobacco Pouch Appearance seen in genital TB

  39. What are the HSG findings suggestive of pelvic tuberculosis ?

  40. Answer: In F. Tubes • Bilateral blocked tubes especially at cornual end • Beaded appearance • Irregular shaggy outline of tubes • Golf club/ sperm head appearance: small sacculation at the filling end of isthmus/ampullary portion of tube • Maltese cross appearance: in fibrotic stage-curved or straight pipe-like appearance of tubes with lack of normal tortuosity • Multiple filling defects, diverticuli or extravasation in tubal wall

  41. Answer: In F. Tubes • Leopard skin appearance: the ampulla of the tube is partially filled with dye giving a speckled appearance • Rosette: the distal end of the tube is filled with dye that has a rosette appearance • Tobacco pouch appearance • Straight thickened, rigid “pipe stem” tubes • Hydrosalpinx/ pyosalpinx • Calcification in tubes

  42. Answer: In Uterus • Moth-eaten appearance: irregular outline of cavity (TB endometritis) • Intra-uterine adhesions (synichae) • Venous/lymphatic intravasation of dye

  43. What is ‘Blue Uterus Sign’? • What is the role of laparoscopy in diagnosis of genital TB?

  44. Answer Laparoscopy should be done carefully to avoid injury to adherent bowel loops; open laparoscopy is preferred. • “Blue uterus” when chromopertubation test done with methylene blue • Acute salpingitis: red, swollen edematous tubes • Tiny tubercles 1-4 mm on surface of organs: tubes, uterus • Hydrosalpinx, pyosalpinx • Tobacco-pouch appearance • Violin string adhesions • Unilateral / bilateral TO masses • Straw colored thick jelly like exudate in POD • Fimbrial biopsy, peritoneal fluid may be taken to confirm the diagnosis

  45. What are the usg findings suggestive of TB?

  46. Answer • Loculated ascites: The presence of fine lacy strands or particulate matter in fluid is due to thin fibrin strands • Bilateral or unilateral tubo-ovarian mass

  47. What is Mitchison & Grosset Hypothesis • What was he referring to?

  48. ANTI-TB DRUGS HAVE NO ACTION INH, RFMSM RIFAMPICIN PYRAZINAMIDE Answer Group I: Fast growing, neutral pH, aerobic Group II: Slow growing, intracellular, acidic Group III: Slow growing, neutral pH, hypoxic Dormant bacilli THE BATTLE AGAINST TUBERCULOSIS CANNOT BE WON UNTIL DRUGS THAT CAN EFFECTIVELY KILL THESE DORMANT TUBERCULOUS BACILLI ARE FOUND.

  49. Which drugs are used in the 4 drug short course treatment? • Why are these drugs used?

  50. Answer

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