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.

Study on the relationship between CXCR3 and its ligands and tubal tuberculosis.

OBJECTIVE: Chemokines play an important role in Mycobacterium tuberculosis infection. We aimed to investigate CXCR3, CXCL9, CXCL10 and CXCL11 to explore the correlation between the severity of tubal tuberculosis and chemokines. METHODS: 26 patients with tubal tuberculosis diagnosed in our hospital from 2016 to 2019 were selected as the experimental group, and 18 female patients who underwent high-risk pregnancy supervision in our hospital from 2016 to 2018 were selected as the control group. The pathological manifestations of tubal tuberculosis were observed by HE staining, the expressions of CXCR3 and its ligands in fallopian tubes were detected by immunohistochemistry. RESULTS: Typical granulomatous structure of tubal tuberculosis was observed by HE staining and most of them were accompanied by massive necrosis in the experimental group, while no granulomatous lesions were found in the control group. The results of immunohistochemical staining showed that CXCR3 and its ligands were expressed in the cytoplasm and nucleus of oviduct epithelial cells and inflammatory cells, in the granuloma area. CXCL9, CXCL10 and CXCL11 were related to the severity of the disease. KEY FINDINGS: CXCR3 and its ligands were positively expressed in tubal tuberculosis, especially CXCL9, CXCL10 and CXCL11 were positively correlated with the severity of fallopian tube disease. SIGNIFICANCE: It is helpful for clinical diagnosis and treatment detection, and provides a new therapeutic target for the study of female genital tuberculosis in the future.

Female genital tuberculosis in light of newer laboratory tests: A narrative review.

Female genital tract tuberculosis (FGTB) is a chronic disease with varied presentation. The diagnosis of FGTB for early institution of treatment remains a clinical challenge. Its laboratory diagnosis is difficult because of paucibacillary nature of the condition and limitation of available diagnostic tests. In view of the intricate problems in diagnosis of FGTB, physicians tend to over treat with empirical anti-tuberculosis drugs. Apart from concerns of drug toxicity, this may be a contributing factor in the increasing incidence of multidrug-resistant TB reported in India. The main goal for advances in TB diagnostics is to reduce delay in diagnosis and treatment. In addition, there should be reduced complexity, improving robustness, and improving accuracy of the laboratory test for diagnosis of Female genital tuberculosis. OBJECTIVE: This narrative review is written with the following objectives. 1) To get a comprehensive overview as well as recent advances in diagnostic test used in the detection of FGTB. 2) To understand the limitations as well as advantages of these laboratory diagnostic test. 3) To provide clinical guidance regarding the detection in susceptible women. METHOD: The literature search was performed using electronic database of Pubmed, Medline, Embase and Google Scholar. Grey literature search was also done. Studies published in English were included. Following keywords were used for search - Tuberculosis, extra pulmonary tuberculosis, female genital tuberculosis, diagnosis of female genital tract tuberculosis. The personal knowledge and experience of authors in the field, helped in archiving the relevant articles. RESULT: Studies suggest that though culture is an invaluable contributor in the diagnosis of FGTB, molecular tests like PCR, LAMP, Xpert MTB/RIF and line probe assays have shown potential and are now being explored to strengthen the diagnostic algorithm of FGTB. CONCLUSION: The use of algorithm approach with combination of both rapid culture and newer molecular techniques will facilitate the accurate and timely diagnosis of FGTB.

Latent genital tuberculosis adversely affects the ovarian reserve in infertile women.

STUDY QUESTION: What is the effect of latent genital tuberculosis (GTB) on ovarian reserve in infertile women? SUMMARY ANSWER: Women with latent GTB have lower ovarian reserves and yield lower numbers of oocytes in IVF. WHAT IS KNOWN ALREADY: Limited evidence suggests that women with GTB may have a low ovarian reserve. Infertile women have a high incidence of latent GTB and treatment improves fertility outcomes. STUDY DESIGN, SIZE, DURATION: This prospective study from February 2013 to January 2016 compared 431 infertile women diagnosed with latent GTB (Group I) to 453 infertile women without latent GTB (Group II). PARTICIPANTS/MATERIALS, SETTING, METHODS: The study was conducted at Shreyas Hospital, Kolhapur, India, a tertiary referral centre for infertility. Women of both groups were 21-38 years of age. Group I consisted of infertile women with proven tubal patency but with latent GTB diagnosed by DNA PCR testing of an endometrial biopsy. Day 2-4 anti-Mullerian hormone (AMH) and antral follicle count (AFC) were assessed in both groups. All women with latent GTB took antituberculosis therapy (ATT). Gonadotropin dosages and oocyte and embryo details were noted in both groups for those who underwent IVF. MAIN RESULTS AND THE ROLE OF CHANCE: Women with latent GTB were younger (29.8 ± 4.4 years vs. 30.8 ± 4.5 years; P = 0.003) and, following adjustment for age, had significantly lower AMH [Median (IQR): 2 (0.9, 4.1) ng/ml vs 2.8 (1.3, 5) ng/ml; P = 0.01] and AFC [Median (IQR): 7 (5, 11) vs 8 (5, 14); P < 0.001]. Post ATT, women with latent GTB yielded fewer oocytes (9.3 ± 7.6 vs. 10.9 ± 8.1; P = 0.01), but had more grade I embryos transferred (1.1 ± 0.5 vs. 0.89 ± 1.0; P = 0.001) and a better implantation rate (26.8% vs. 17.5%; P = 0.004) in IVF compared to women in Group II. Group I had a higher pregnancy rate compared to Group II (51.6% vs. 40.5%; P = 0.001), through various treatment modalities. Considering the adequacy of the sample size and use of robust ovarian reserve markers, the role of chance is minimal. LIMITATIONS REASONS FOR CAUTION: The study is limited to an infertile population visiting a tertiary referral centre. The mechanisms by which latent GTB infection would lead to ovarian damage are unclear. WIDER IMPLICATIONS OF THE FINDINGS: It is believed that latent GTB is without any clinical significance. However, a low ovarian reserve in young women with latent GTB necessitates considering it as a cause of infertility, in women with prolonged infertility. These women may experience an accelerated decline in ovarian reserve with reduced success in achieving biological parenthood. Clinicians must be aware of this condition and its consequences while managing infertility. STUDY FUNDING/COMPETING INTEREST(S): This study was funded by Sushrut Assisted Conception Clinic, Shreyas Hospital, Kolhapur, India. The authors have no conflicts of interest to declare. TRIAL REGISTRATION NUMBER: N/A.

[RISK FACTORS AND SPECIAL ASPECTS FORGENITAL TUBERCULOSIS DIAGNOSTICS].

Was examined 453 women, who applied to National Center for Tuberculosis and Lung Diseases for genital tuberculosis diagnostics. GTB was detected in 289 cases, in 164 cases GTB results was negative (control group). In 10 cases GTB was combined with pulmonary tuberculosis (OR-1,13). Risk factors are previous diseases of female reproductive organs- intracellular infection (OR-1,08), sexually transmitted diseases (OR-1,25), nonspecific inflammatory diseases (OR-1,009), interruption of pregnancy (OR-1,26), artificial abortions (OR-1,11), the most specific signs of Genital Tuberculosis is a pain in the stomach area (P-0,023), dysmenorrhoea (P-0,00001), intestinal obstruction (P-0,0006), heat (P-0,00001), liquid presence in posterior vault (P-0,007), hydrosalpinx (P-0,00001), Fallopian tubes deformation (P-0,000003), oophoritic cyst (P-0,067), adhesive process in small pelvis (P-0,0006). Lab tests used to study material showed high specificity of cytological (Sp - 78,05%), bacteriological (Sp - 96.4%) and morphological (Sp - 98.78%) methods, as a result of their low sensitivity (Se - 28.03%, 96.4%, 98.78%, respectively). As for PCR diagnostics, in this case both the sensitivity and specificity is of high level (Se - 77.98%, Sp - 82.11%).

NMR-based metabonomics for understanding the influence of dormant female genital tuberculosis on metabolism of the human endometrium.

STUDY QUESTION: Does investigation of metabolic perturbations in endometrial tissue of women with dormant genital tuberculosis (GTB) during the window of implantation (WOI) assist in improving the understanding of endometrial receptivity? SUMMARY ANSWER: In dormant GTB cases significant alterations in endometrial tissue metabolites occur, largely related to energy metabolism and amino acid biosynthesis in dormant GTB cases. WHAT IS KNOWN ALREADY: As an intracellular pathogen, Mycobacterium tuberculosis strongly influences the metabolism of host cells causing metabolic dysregulation. It is also accepted that dormant GTB impairs the receptive status of the endometrium. Global metabolic profiling is useful for an understanding of disease progression and distinguishing between diseased and non-diseased groups. STUDY DESIGN, SIZE, DURATION: Endometrial tissue samples were collected from patients reporting at the tertiary infertility care center during the period September 2011-March 2013. Women having tested positive for GTB were considered as the study group (n = 24). Normal healthy women undergoing sterilization (n = 26) and unexplained infertile women with repeated IVF failure (n = 21) volunteered to participate as controls. PARTICIPANTS/MATERIALS, SETTING, METHODS: Endometrial tissue samples were collected 6-10 days after confirmation of ovulation. PCR and BACTEC-460 culture were used for diagnosing GTB. Proton nuclear magnetic resonance (1H NMR) spectra of tissue were recorded using a 700 MHz Bruker Avance AV III spectrometer. Following phase and baseline correction of all NMR spectra by Bruker Topspin 2.1 software, spectral peak alignment of the data was performed. Multivariate analysis was applied to all spectra and individual metabolites identified and multiple correlation analysis was performed. MAIN RESULTS AND THE ROLE OF CHANCE: Leucine, isoleucine, acetate, lactate, glutamate, glutamine, methionine, lysine, creatine, glycogen, glycine, proline and choline were found to be significantly increased (P < 0.05) in endometrial tissue of women with dormant GTB compared with unexplained infertile women with repeated implantation failure. Valine, citrate, succinate and aspartate were also observed to be significantly up-regulated (P < 0.01). Furthermore, a significant decrease in glucose (P < 0.05), threonine (P < 0.05), tyrosine (P < 0.01) and phenylalanine (P < 0.0001) was observed in women with dormant GTB. Pearson's correlation analysis between the expression of various endometrial receptivity markers and metabolites showed a significant negative correlation (-0.236 to -0.545, P < 0.05). Also, the metabolites were positively correlated with endometrial receptivity markers (0.207 to 0.618, P < 0.05). LIMITATIONS, REASONS FOR CAUTION: It is often difficult to diagnose dormant GTB because it tends to exist without any clinical signs or symptoms. In addition, the diagnosis of GTB by culture remains a challenge due to low detection rates and its paucibacillary nature. Testing for prostate-specific antigen or the Y chromosome in order to account for the possible influences of recent exposure to semen on endometrial metabolism would be important. WIDER IMPLICATIONS OF THE FINDINGS: The metabolic changes associated with the dormant tubercle infection are of potential relevance to clinicians for the treatment of dormant GTB-related infertility. STUDY FUNDING/COMPETING INTERESTS: Government of India, Indian Council of Medical Research. There are no conflicts of interest.

Effect of Antitubercular Therapy on Endometrial Function in Infertile Women with Female Genital Tuberculosis.

OBJECTIVE: Evaluation of anti-tubercular therapy on endometrium in Female Genital Tuberculosis. METHOD: Total of 50 women having FGTB on endometrial aspirate (positive AFB, epithelioid granuloma, positive PCR, laparoscopy or hysteroscopy findings) were enrolled. Ultrasound was performed for endometrial thickness, mean resistive index and pulsatility index before and after anti-tubercular therapy (ATT). Diagnostic hysteroscopy was performed for intra-uterine adhesions and to visualise cavity before and after ATT. RESULTS: Menstrual cycle improved after anti-tubercular therapy (ATT). Endometrial aspirate findings improved with disappearance of AFB, epithelioid granuloma and decrease in PCR (94%vs 33%). After ATT, ultrasound examination of endometrial thickness improved from 7.01±1.48 mm to 7.51±1.48 mm while mean resistive index and pulsatility index decreased from 0.729±0.304 to 0.692±0.399 and 1.180 to 1.138. With ATT, improvement was seen in hysteroscopic findings with normal looking cavity increasing from 18(36%) to 34(72.1%) and pale looking cavity decreasing from 20(42.5%) to 8(16.8%). Before ATT, prevalence of intrauterine adhesions was 62% which decreased to 28.7% after ATT. Improvement was significant only in grade I adhesions from 34% to 2.1%, (p<0.001). There was no improvement in higher grade of intrauterine adhesions with ATT with grade II (6% vs 4.2%) and grade 2a (4% vs 2.1%), grade III being (2% vs 2.1%), grade II a (4% vs 4.2%), grade Va (4% vs 4.2%) and grade Vb (8% vs 10.6%) before and after ATT respectively. CONCLUSION: Early ATT improved menstrual cycle, endometrial thickness and reduced incidence of grade I adhesions. Advanced stages did not show any improvement.

[Implication of laparoscopy in diagnostics of genital tb among women through cytohistological testing of bioptic specimen].

Diagnostics of genital TB among women is a serious challenge because of the absence of specific clinical manifestation and difficulty to obtain material for bacteriological verification of the pathogen. All the cases with ascites and masses in pelvic cavity must undergo thorough testing to exclude tuberculosis. The present article describes 14 suspect cases of genital TB, where along with the mandatory clinical diagnostic studies (including PCR of ascites and bacteriological testing for TB, also on carcinoma of CA-125 ovary) they have conducted laparoscopy, with further cytological and bacteriological testing of bioptic sample. This method allowed us to diagnose genital and abdominal tuberculosis among women in 85,7% of cases through cytologic and histologic testing and to exclude ovarian carcinoma. Effectiveness of laparoscopy has been confirmed in diagnostics of genital and abdominal TB.

Effects of salpingectomy and antituberculosis treatments on fertility results in patients with genital tuberculosis.

AIM: The aim of this study was to demonstrate the effects of tubal surgery and antituberculosis treatments in patients with genital tuberculosis. MATERIAL AND METHODS: A total of 38 infertile women who had been diagnosed with pelvic tuberculosis and who had had laparoscopy and hysteroscopy were recruited into the study. All women with female genital tuberculosis were divided into two groups: group 1 (salpingectomized, n=21) and group 2 (not salpingectomized, n=15). Both of the groups were treated with antitubercular therapy for 6-12 months. RESULTS: There was no significant difference in level of gonadotrophins used, estradiol levels on human chorionic gonadotrophin day, mean and mature oocytes retrieved, mean embryos transferred, or cancellation and fertilization rates. Only the number of days of stimulation was statistically significantly higher in group 1 compared to group 2 (10.4±2.3 vs 9.2±1.8; P=0.048). Although it did not reach the statistically significant level, clinical pregnancy rate was higher in group 1 (37.5%, 12/32 vs 23.8%, 5/21; P=0.306). Although not statistically significant, number of ongoing pregnancies per embryo transfer, spontaneous abortion rates before 20 weeks of gestation and take-home baby rates were higher in group 1 compared to group 2 (15.5%, 12/77 vs 6.6%, 3/45; P=0.150; 28.1%, 9 vs 23.8%, 5; P=0.600; 9%, 3 vs 0; P=0.160, respectively). CONCLUSION: Salpingectomy is an option for treatment in patients diagnosed with pelvic tuberculosis and infertility to improve both clinical pregnancy rates and take-home baby rates in patients treated with antituberculosis therapy for 12 months.

Tuberculosis of the cervix mimicking cervical cancer.

Tuberculosis of the cervix is a rare disease and accounts for 0.1-0.65% of all cases of tuberculosis. We present an unusual case of a 57 years old female who presented with chief complaints of Serosaguineous vaginal discharge of one year duration and irregular firm cervix with contact bleeding and was clinically diagnosed to have cervical cancer. Histopathology revealed typical findings of cervical tuberculosis. Cervical tuberculosis should be considered as a differential diagnosis of cervical malignancy. The clinical presentation and diagnosis of cervical tuberculosis is reviewed.

The effect of tuberculosis on ovarian reserve among women undergoing IVF in India.

OBJECTIVE: To assess ovarian reserve in infertile women with genital tuberculosis planning to undergo in vitro fertilization and in women of proven fertility, and compare the findings. METHODS: A cross-sectional study was conducted at an outpatient gynecology unit with 104 women with genital tuberculosis and 104 healthy controls. In each group, ovarian reserve tests consisted in estimating serum levels of follicle-stimulating hormone (FSH), luteinizing hormone (LH), estradiol, and inhibin B on day 3 of a natural menstrual cycle. On the same day ovarian volume, number of antral follicles, and ovarian stromal blood flow were also estimated. RESULTS: The mean FSH and LH levels were significantly higher, and the mean inhibin B levels were significantly lower, among the participants with genital tuberculosis than among the controls. Conversely, the mean ovarian volume and the mean number of antral follicles were significantly lower among the participants with genital tuberculosis, as were the mean peak systolic velocity and pulsatility index for each ovary. CONCLUSION: There is no single absolute predictor of ovarian reserve, but combining the current assessment methods provides a close estimation of a woman's reproductive capability. Values for the studied markers showed that ovarian reserve was compromised in women with genital tuberculosis.

Targeted detection of 65 kDa heat shock protein gene in endometrial biopsies for reliable diagnosis of genital tuberculosis.

OBJECTIVE: To evaluate the clinical utility of PCR compared with other available diagnostic modalities in prompt diagnosis of female genital tuberculosis causing infertility. STUDY DESIGN: Prospective case-controlled trial. Premenstrual endometrial biopsy specimens were collected from 150 infertile women of reproductive age group suspected of having genital tuberculosis. All patients underwent diagnostic endoscopy (laparoscopy and hysteroscopy) and the samples obtained were subjected to microscopy, culture by the BACTEC 460 TB System, histopathology and polymerase chain reaction (PCR) for detection of 165 bp region of 65 kDa gene of Mycobacterium tuberculosis. The results were correlated with the laparoscopic findings. RESULTS: While the laparoscopy/hysteroscopy findings were indicative of tuberculosis in 12.6% of cases, 14.6% of the specimens showed evidence of 65 kDa gene of M. tuberculosis and only 3.33%, 1.33% and 0.66% were positive by culture, smear and histopathology, respectively. CONCLUSION: Since laparoscopy, hysteroscopy other endoscopic procedures are associated with operative risks and may cause flaring of infection, and other conventional laboratory tests including histopathology have poor sensitivity, PCR-based detection of 65 kDa gene of M. tuberculosis in endometrial biopsy specimens could be a promising molecular diagnostic technique compared to conventional methods of diagnosis.

Comparative analysis of endometrial blood flow on the day of hCG by 2D Doppler in two groups of women with or without genital tuberculosis undergoing IVF-ET in a developing country.

OBJECTIVE: To evaluate the endometrial blood flow by two-dimensional power Doppler ultrasound as possible implantation markers and pregnancy predictors in women with and without genital tuberculosis undergoing in vitro fertilization-embryo transfer cycle (IVF-ET). METHODS: This was a prospective observational study. A total of 183 infertile women were recruited from our IVF-ET program from January to December 2009. Women with tubal factor, male factor and unexplained infertility were included in the study. RESULTS: The age, duration of infertility and BMI of the women were comparable in both the groups. The mean gonadotropin usage in Group 1 was 2,881.3 IU (±SD 949.7) and 3,077.8 (±SD 927.9) in Group 2. Total number of eggs obtained, duration (days) of stimulation, Estradiol (E2) concentration and endometrial thickness (in mm) showed no significant difference in the two groups. Even the peak systolic velocity, pulsatility index (PI) and resistance index (RI) was not statistically significant between the two groups. Pregnancy and implantation was higher in women with endometrial flow in zone 3 in both the groups though it did not reach any statistical significance. CONCLUSION: The present study showed no difference in endometrial blood flow and pregnancy rates in patients with or without genital tuberculosis.

[TUBERCULOUS SALPINGITIS IN THE STAGE OF CALCIFICATION TO CASEOUS NECROSIS IN TEENAGE GIRL].

The authors observed a case of pinched, calcified, caseously degenerated right uterine appendages in girls aged 14 and 11 years. The disease showed mild symptoms and it was occasionally detected by intravenous urography. Both patients underwent surgery--elimination of tuberculous salpingitis with calcified caseous necrosis. No treatment in the former case and specific treatment in the latter led to two different outcomes: late recurrence and recovery. Pinched, calcified, caseously degenerated uterine appendages are a rare pathology in children in particular. Ovarian dermoid cysts and calcified lymph nodes are differentially diagnosed. Diagnosis and treatment require surgical intervention (laparotomy, laparoscopy), sanitization of an infection focus, chemotherapy.

Association of pelvic tuberculosis with tubal factor infertility.

Tubal block is a common cause of infertility. Therefore Laparoscopy or Hysterosalphingoraphy or Hydrosonosalphingography are accepted methods for diagnosis of tubal block. Genital tuberculosis has a world wide distribution, more common in developing countries. Tubal block is the sequel of that disease. This prospective study by determination of Acid Fast Bacilli (AFB) in the endometrium of infertility patients was carried out in 60 patients at the Infertility unit, department of Obstetrics & Gynecology Bangabandhu Sheikh Mujib Medical University (BSMMU) during January 2005 to December 2006. In this study AFB positive in endometrium was in 14(46.7%) cases and 4(13.3%) in control. Out of 30 cases 60% had primary sub-fertility and 40% had secondary sub fertility. Most common tubal pathology was adhesion in 11(36%) cases. Others were beaded and tortuous in 8(26.7%) and hydrosalphix in 6(20%) and tube was dilated in 2(6.7%) cases. There were bilateral tubal block in 18(60%) and unilateral tubal block in 12 (40%) cases.

Postoperative flare-up of genital tuberculosis: a clinical reality.

We report three cases of flare-up of tuberculosis (TB) following genital surgery. In two cases, both patients developed abdominal distension postoperatively with vomiting and fever following total laparoscopic hysterectomy. Polymerase chain reaction (PCR) analysis of fluid detected and aspirated from the abdomen under ultrasound guidance was positive for Mycobacterium tuberculosis. In another instance, the patient developed abdominal distension with discharge per vaginum following a vaginal hysterectomy. X-ray of the abdomen showed dilated bowel loops and also a pseudo acetabular right hip joint suggestive of TB. PCR analysis of ascitic fluid was positive for TB. All patients responded to anti-tuberculosis treatment.

[Recovered reproductive function in female patient with sever genital tuberculosis]. / Vosstanovlenie reproduktivnoi funktsii bol'noi s tiazheloi formoi genital'nogo tuberkuleza.

In severe genitoperitonial tuberculosis, conglomerate forms of the disease, and liquid accumulation between intestinal loop adhesions, laparotomy may verify the diagnosis in the shortest time while other diagnostic methods cannot be used due to contraindications for them. The operation should be maximally saving and only diagnostic. Timely combined antituberculous treatment concurrently with surgical interventions yields good results of recovered reproductive function.