Computed tomographic findings in female genital tuberculosis tubo-ovarian masses.

Female genital tuberculosis (FGTB) is a common cause of infertility in developing countries. It can manifest as menstrual disturbances, infertility and pelvic masses. OBJECTIVE: To evaluate the role of computed tomography in diagnosis of female genital tuberculosis with tubo-ovarian (adnexal) masses. METHODS: It was a prospective study over a four year period (July 2015 to August 2019) in a tertiary referral centre over 33 patients presenting with tuberculosis and tubo ovarian masses only. 75 total cases of FGTB diagnosed on composite reference standard (evaluation of AFB bacilli in microscopy or culture or endometrial biopsy, gene expert, epitheloid granulomas on endometrial biopsy or definitive or possible findings of FGTB on laparoscopy). Detailed history taken, clinical examination, baseline investigations and endometrial biopsy were done in all cases. Computed tomography was performed in women presenting with infertility, tubo ovarian masses on clinical examination and laboratory investigations. A total of 33 cases were evaluated. RESULTS: Mean age, body mass index, parity and history of TB contact were 27.5 ± 4.2 year, 22.7 ± 3.6 kg/m2, 0.27 ± 0.13 and 44.4% respectively. Infertility was primary in 72.72% and secondary in 27.23%. Case wise mean duration being 5.8 years, menstrual dysfunction was seen in 45.45% cases. Abdominal discomfort with pain and lump were seen in all 33 (100%) cases. Abdominal lumps were felt in 4 (12.12%) cases while adnexal mass was seen in all 33 (100%) cases being unilateral in 18 (54.54%) and bilateral in 15 (45.45%). Mean ESR was 33.4mm in first hour while mean leucocyte count was 6128 ± 2854 per cubic mm. Infectious mantoux test (>10mm) was seen in 14 (42.82%) cases while abnormal X ray chest was seen in 9 (27.27%) cases. Diagnosis of FGTB was made by positive AFB n microscopy or culture of endometrial biopsy in 5 (15.15%) cases, positive gene expert in 6 (18.18%) cases, positive polymerase chain reaction in 32 (96.96%) cases, epitheloid granulomas on histopathology of endometrial biopsy in 7 (21.21%) cases, definitive findings of tuberculosis in 15 (45.45%) cases and a possible findings of tuberculosis inn 18 (54.54%) cases. Various CT findings were pelvic mass (100%), unilateral pelvic mass in 18 (54.54%), bilateral pelvic mass in 15 (45.45%), cystic mass (24.2%), solid mass (21.2%), mixed mass (54.54%), mass showing multilocular caseous necrotic enhancements (12.12%), ascites (42.4%), thickening and enhancement of peritoneum in 14 (42.42%), nodules in 24.2%, smooth in 18.8%, pelvic adhesion in 6 (18.18%), lymphadenopathy in 8 (24.3%) with calcifications (9.09%) and central necrosis (52.5%). Other CT findings were thickening and enhancement of bowel wall (12.12%), hepatic TB (3.03%), splenic TB (3.03%), omental thickening (9.09%) and omental calcification (3.03%) cases. CONCLUSION: Computed tomography appears to be a useful diagnostic modality in diagnosis of tuberculosis tubo ovarian masses and may help avoid unnecessary surgery.

Imaging Spectrum of Female Genital Tuberculosis: A Comprehensive Review.

Female genital tuberculosis is a relatively uncommon form of extrapulmonary tuberculosis that is under-reported and under-recognized. The early course of the disease has fewer manifestations, resulting in late presentation with grave complications like infertility and ectopic pregnancy. Also, difficulty in isolation of the causative bacteria further delays the diagnosis. The radiologist should be well versed with imaging findings of female genital TB to help the clinicians to initiate prompt treatment. This review shall cover imaging findings of female genital TB involving fallopian tubes, uterus, ovaries, cervix, vagina, and vulva on different imaging modalities. Fallopian tubes are almost always involved in genital TB followed by uterus and ovaries. Hysterosalpingogram and ultrasound can best detect tubercular changes in fallopian tubes and uterus whereas cross-sectional imaging is essential for the diagnosis of ovarian or peritoneal TB as they closely mimic malignancy. Cervical, vaginal, or vulval TB produces nonspecific changes and histopathological diagnosis is required for confirmation of the diagnoses. Close differential diagnosis on imaging like malignancy or pelvic inflammatory disease, are also discussed with a brief discussion of the pathogenesis.

Sharma's parachute sign a new laparoscopic sign in abdomino pelvic tuberculosis.

AIMS: To demonstrate a new laparoscopic sign "Sharma's Parachute sign" in abdominopelvic tuberculosis in women with infertility. METHODS: A total of 104 women who were diagnosed to have abdominopelvic tuberculosis, on endometrial sampling or on laparoscopy were enrolled in this ongoing study on tuberculosis in infertility. A new laparoscopic "Sharma's parachute sign" was looked for in these cases on laparoscopy. RESULTS: The mean age, pairty and duration of infertility was 27.6 years, 0.58 and 4.1 years respectively. Menstrual dysfuction were common especially hypomenorrhoea (34.61%), oligomenorrhoea (36.53%) along with constitutional symptoms and abdomino pelvic pain or lump. Diagnosis of abdominopelvic tuberculosis was made by identification of acid fast bacilli (AFB) on microscopy or culture of endometrial aspirate or peritoneal biopsy or positive gene Xpert or positive polymerase chain reaction (PCR) or histopathological demonstration of epithelioid granuloma on endometrial or peritoneal biopsy, various laparoscopic findings on pelvic and abdominal organs were tubercles and shaggy areas (white deposits, caseous nodules encysted ascites, abdominal and pelvic adhesions, tubal findings (hydrosalpinx, pyosalpinx, beaded or calcified tubes). A new "Sharma's parachute sign"in which ascending colon was totally adherent to anterior abdominal wall with its mesocolon looking like an open parachute with small caseous nodule was seen in 11 (10.5%) cases. CONCLUSION: Diagnostic laparoscopy is an important investigation for abdominopelvic tuberculosis showing various adhesions including new parachute sign.

Female genital tuberculosis and infertility: serial cases report in Bandung, Indonesia and literature review.

BACKGROUND: Female genital tuberculosis (FGTB) is a Mycobacterium infection in the reproductive organs which often leads to infertility. FGTB is either asymptomatic or causes uncharacteristic clinical presentations, making an early diagnosis is challenging. Our aims were to evaluate the clinical presentations, the process to confirm the diagnosis and followed-up the patients who had undergone laparoscopy at our center. FGTB has been reported from many countries, but has never been reported from Indonesia. Here we present case studies to document the presence of FGTB in Indonesia. CASES PRESENTATION: There were three patients admitted to our center; two patients were admitted with irregular menstrual cycle as their chief complaint, while one patient came due to infertility. The results from laparoscopy were suggestive of FGTB; including the presence of caseating granulomas surrounded by epithelioid cells, lymphocytes, plasma cells, and Langhans giant cells. Additionally, PCR testing confirmed presence of MTB. Subsequent to diagnosis, continuous TB medications was administered with excellent clinical outcome in two patients (pregnant in 18 months after under gone laparoscopy). The infertile patient remain in one of the treated patient above. CONCLUSION: In infertile patients who live in countries where Tuberculosis is an endemic disease, such as Indonesia, a comprehensive history taking, along with ultrasonography results can be used to diagnose FGTB. Confirmation of this diagnosis can be achieved through polymerase chain reactions result. Timely diagnosis and treatment are imperative to prevent any permanent injury to patient's reproductive organs.

Hysterosalpingographic features of cervical abnormalities: acquired structural anomalies.

Cervical abnormalities may be congenital or acquired. Congenital cervical structural anomalies are relatively uncommon, whereas acquired cervical abnormalities are commonly seen in gynaecology clinics. Acquired abnormalities of the cervix can cause cervical factor infertility and recurrent spontaneous abortion. Various imaging tools have been used for evaluation of the uterine cavity and fallopian tubes. Hysterosalpingography (HSG) is a quick and minimally invasive tool for evaluation of infertility that facilitates visualization of the inner surfaces of the uterine cavity and fallopian tubes, as well as the cervical canal and isthmus. The lesions of the uterine cervix show various imaging manifestations on HSG such as narrowing, dilatation, filling defects, irregularities and diverticular projections. This pictorial review describes and illustrates the hysterosalpingographic appearances of normal variants and acquired structural abnormalities of the cervix. Accurate diagnosis of such cases is considered essential for optimal treatment. The pathological findings and radiopathological correlation will be briefly discussed.

Hysterosalpingography and ultrasonography findings of female genital tuberculosis.

Genital tuberculosis (TB) is an important cause of female infertility in the world, especially in developing countries. Majority of infertility cases are due to involvement of the fallopian tubes (92%-100%), endometrial cavity (50%), and ovaries (10%-30%); cervical and vulvovaginal TB are uncommon. Genital TB has characteristic radiological appearances based on the stage of the disease process (acute inflammatory or chronic fibrotic) and the organ of involvement. Hysterosalpingography (HSG) and ultrasonography (US) remain the main imaging modalities used in the diagnosis of genital TB. HSG is the primary modality for evaluating uterine, fallopian tube, and peritubal involvement and also helps in evaluating tubal patency. US, on the other hand, allows simultaneous evaluation of ovarian and extrapelvic involvement.

Comparison of PET/CT with other imaging modalities in women with genital tuberculosis.

OBJECTIVE: To compare findings with 2-deoxy-2-((18)F)fluoro-D-glucose positron emission tomography combined with computed tomography ((18)F-FDG-PET/CT) with findings obtained using ultrasound (US), magnetic resonance imaging (MRI), and CT in patients with proven tubercular tubo-ovarian masses. METHODS: Seventeen patients with proven tubercular tubo-ovarian masses underwent (18)F-FDG-PET/CT imaging and the findings were compared with US (for all patients), MRI (for 9 patients), CT (for 4 patients), and laparotomy or laparoscopic findings (for 14 patients). RESULTS: Eleven patients (64.7%) had unilateral tubo-ovarian masses, with activity in 6 masses (35.3%); 4 patients (23.5%) had bilateral tubo-ovarian masses, with activity in all masses; and 2 patients (11.76%) had unilateral space-occupying lesions, with activity in 1 lesion. The detection rates of tubo-ovarian masses with (18)F-FDG-PET/CT were similar to, but the characterization of adnexal masses was less than, those obtained with CT or MRI. Finally, (18)F-FDG-PET/CT was equally accurate as laparoscopy or laparotomy in detecting the presence, laterality, and activity of tubo-ovarian masses. CONCLUSION: Imaging with (18)F-FDG-PET/CT is noninvasive and appears to be clinically useful for the diagnosis of tubercular tubo-ovarian masses.

Genital tuberculosis as the cause of tuboovarian abscess in an immunosuppressed patient.

BACKGROUND: Although tuberculosis (TB) is a major health problem worldwide, primary extrapulmonary tuberculosis (EPTB), and in particular female genital tract infection, remains a rare event. CASE REPORT: A 35-year-old human immunodeficiency virus (HIV) seropositive woman of African descent with lower abdominal pain and fever of two days duration underwent surgery due to left adnexal mass suggesting pelvic inflammatory disease. The surgical situs showed a four quadrant peritonitis, consistent with the clinical symptoms of the patient, provoked by a tuboovarian abscess (TOA) on the left side. All routine diagnostic procedures failed to determine the causative organism/pathogen of the infection. Histopathological evaluation identified a necrotic granulomatous salpingitis and specific PCR analysis corroborated Mycobacterium tuberculosis (M. Tb). Consequently, antituberculotic therapy was provided. CONCLUSION: In the differential diagnosis of pelvic inflammatory disease, internal genital tuberculosis should be considered. Moreover, physicians should consider tuberculous infections early in the work-up of patients when immunosuppressive conditions are present.

Postmenopausal tuberculosis endometritis.

Tuberculosis remains a global health problem, primarily in developing countries with inadequate health services. A significant portion of tuberculosis in these settings is extrapulmonary, including tuberculosis of the genitourinary tract. Patients with genital tuberculosis are usually young women detected during work up for infertility. After menopause, tuberculosis of the endometrium is a rare possibility probably because of the decreased vascularity of the tissues. We present a case of endometrial tuberculosis with postmenopausal vaginal bleeding.

Management of bilateral fallopian tube carcinoma coexistent with tuberculous salpingitis.

Primary carcinoma of the fallopian tube is a rare gynecologic malignancy. Chronic tubal inflammation is associated with primary carcinoma of the fallopian tube. There are only a few reports on primary carcinoma of the fallopian tube coexisting with tuberculous salpingitis. We are reporting a patient with both the primary carcinoma of the fallopian tube and tuberculous salpingitis, which were detected in bilateral fallopian tubes. The histologic type was serous adenocarcinoma. The patient was treated with total abdominal hysterectomy, bilateral salpingo-oophorectomy, infracolic omentectomy, and bilateral pelvic lymphadenectomy followed by chemotherapy consisting of paclitaxel and cisplatin. She has been alive without evidence of disease for 18 months.

[A case of advanced genital tuberculosis--differential diagnostics and surgical aspects].

The authors report a case of advanced genital tuberculosis. The diagnostic difficulties and treatment are discussed.

Female genital tuberculosis: hysterosalpingographic appearances.

Genital tuberculosis is an important cause of infertility in developing countries and hysterosalpingography (HSG) is the initial procedure performed for the evaluation. Reviewing 37 cases of female genital tuberculosis, we encountered various appearances on HSG. Of 579 HSGs performed over a period of 4 years, 492 (85%) were performed as part of infertility work up. Genital tuberculosis was found in 6.3% of all the patients who underwent HSGs and 7.5% of all patients investigated for infertility. The various features of proven tuberculosis cases are illustrated in this pictorial review. We briefly discuss the pathology and these appearances along with radiopathological correlation.

[Comparative analysis of a new modification of segmental tuberculin test with the routine Koch test]. / Sravnitel'nyi analiz novoi modofokatsii segmentarnykh tuberkulinovykh prob s traditsionnoi proboi Koch.

A focal reaction plays the leading role in the assessment of segmental tests (ST). The sensitivity of ST is 72.4% and that of the Koch test is 64.5%, their specificity is 94.1 and 80.0%, respectively. A 10% or more increase in adenosine deaminase during peritoneal fluid ST indicates to the exacerbation of genital tuberculosis. Analysis of the cellular composition of peritoneal fluid from the Douglas space is proposed as a criterion for a focal reaction. There are ultrasound symptoms which accompany the exacerbation of an inflammatory process in the genitals in response to ST and which are indicative of a positive focal reaction. The minimum tuberculin load and lack of contraindications allow ST to be introduced into the practical work of tuberculosis facilities.

[Analysis of 20 cases of pelvic tuberculosis initially suspected of ovarian carcinoma].

OBJECTIVE: To analyze the clinical characteristics of female pelvic tuberculosis for the differentiation from ovary carcinoma. METHODS: Twenty patients who were confirmed having pelvic tuberculosis from March 1994 to May 2002 were retrospectively studied. RESULTS: Poor economic condition, history of tuberculosis or contact with tuberculosis, and fever were among the most important factors in differentiating pelvic tuberculosis from advanced ovarian cancer. Pelvic mass and ascites were present in all of the 20 patients, abdominal distension in 16, abdominal pain in 12, fever in 16, lost of weight in 13, and diarrhea in 6. The level of serum CA125 ranged from 65 U/L to 1,069 U/L. Peritoneal effusion cytology was studied in 16 cases before operation. CONCLUSIONS: The clinical differentiation of female pelvic tuberculosis from ovary carcinoma was difficult. Pelvic tuberculosis should be considered in young women presented with pelvic mass, ascites, fever, an elevated CA125 level and negative cytology, and with a history of tuberculosis or contact with tuberculosis.

[Clinical picture of genital tuberculosis in different forms of its pathogen]. / Klinicheskaia kartina genital'nogo tuberkuleza pri razlichnykh formakh vozbuditelia.

Improvement of bacteriological diagnosis is of great value for the clinical picture of genital tuberculosis. The purpose of the study is to reveal the clinical features of genital tuberculosis in L-forms of Mycobacterium tuberculosis (MBT) versus traditional bacteriological methods and polymerase chain reaction (PCR) test with MBT DNA. A hundred and fourteen patients with verified active genital tuberculosis were examined. They were divided into 3 groups: 1) 36 patients with L-forms of MBT in the endometrial scrapes; 2) 32 with bacteriologically verified GT; 3) 46 with positive PCR test. A control group (Group 4) comprised 120 patients with NGD. Among the patients with L-forms there were prevalent females aged 21-40 years (83.4%). These patients had a history of spontaneous abortions more frequently than patients from other groups, in a third was found to have MBT with their L-variants. Signs of intoxication were observed in 47.2%. Oviductal obliteration and specific changes typical of tuberculosis were revealed on a hysterogram in 63.9%, other forms of prior and current extragenital tuberculosis were detected in a half of cases, traces of prior pulmonary tuberculosis were observed in 15%, 63.9% of the patients with L-forms and in 87% of those with positive PCR test were found to have pathological changes in the endometrium, which is indirectly indicative of its lesion. Thus, detection of L-forms of MBT in the endometrial scrapes leads to the conclusion that this is an active sluggish hematogenic tuberculous process, which is evidenced by a complex clinical and laboratory study.

Case report: abdominal cocoon associated with tuberculous pelvic inflammatory disease.

Abdominal cocoon is a rare acquired condition in which there is encapsulation of the small bowel by a fibrous membrane. The authors describe a case wherein an organism was identified for the first time. The clinical, pathological and radiological features of this unusual disease are reviewed. Peritoneal encapsulation, a related subject, is also discussed.