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.ObjectiveTo evaluate the role of computed tomography in diagnosis of female genital tuberculosis with tubo-ovarian (adnexal) masses.MethodsIt 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.ResultsMean 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.ConclusionComputed tomography appears to be a useful diagnostic modality in diagnosis of tuberculosis tubo ovarian masses and may help avoid unnecessary surgery.     

An evaluation of Composite Reference Standard (CRS) for diagnosis of Female Genital Tuberculosis

BackgroundFemale genital tuberculosis (FGTB) is a common cause of infertility in developing countries. Its diagnosis is difficult due to its paucibacillary nature, with no single test having high sensitivity and specificity. This study is to share the experience of using Composite Reference Standard (CRS) for the diagnosis of FGTB.MethodsThis is a prospective study conducted between September 2017 to June 2019, over 100 infertile females found to have FGTB on composite reference standard which consisted of acid-fast bacilli on microscopy or culture, histopathological evidence of epithelioid granuloma, positive gene Xpert on endometrial sample or definite or probable finding of FGTB on laparoscopy.ResultsA total of 100 infertile women (78% primary, 22% secondary) found to have FGTB on CRS were enrolled in this study. Mean age, body mass index, parity and duration of infertility were 28.2 years, 23.17 kg/m², 0.24 ± 0.12 and 2.41 years respectively. Various symptoms were scanty menses (16%), irregular cycle (7%), dysmenorrhea (11%), pelvic pain (11%). Various signs were vaginal discharge (65%), adnexal mass (6%), tubo-ovarian mass on ultrasound (15%), abnormal hysterosalpingography findings (57.14%), positive polymerase chain reaction test (65%) and abnormal hysteroscopy (82.2%). The positive findings on CRS were positive AFB on microscopy or culture (3%), positive gene Xpert (28%) (done in some cases), epithelioid granuloma on histopathology (13%), definite findings on laparoscopy like tubercles, caseous nodules and beaded tubes in (57.19%) patients while probable findings of FGTB like straw colored fluid in POD, extensive dense pelvic, peri-tubal, peri-ovarian adhesions; hydrosalpinx; tubo-ovarian mass; thick fibrosed tubes; mid tubal block; peri hepatic adhesions (Fitz Hugh Curtis Syndrome); hyperemia of tubes/blue uterus on chromotubation were seen in (48.8%) patients. All patients found to be positive on CRS were given 6 months of anti-tubercular therapy.ConclusionThis study demonstrates the high reliability of use of composite reference standard for diagnosis of FGTB.     

Evaluation of implantation markers and immune cell infiltration in endometrial biopsy of female genital tuberculosis

BackgroundFemale genital tuberculosis (FGTB) causes infertility in a significant number of females. The immunological impact of tuberculosis on endometrium in infertile females has not been studied before. The present study was designed to evaluate markers related to infiltrating immune cells and implantation in endometrial aspiration from infertile females and correlate with conventional tests and polymerase chain reaction (PCR) for tuberculosis (TB).MethodsIt was a prospective cohort study with 385 patients out of which IHC was done in 306 over a period of 3 years from 2013 to 2016 in a tertiary care hospital. Women with infertility, 20–35 years of age, without history of pulmonary TB or intake of antitubercular therapy were included. Endometrial samples were subjected to PCR for TB along with microbiological and histological examination for TB. Immunohistochemistry for CD45, CD3, CD20, CD4, CD8, CD68, CD138, Interferon gamma, Interleukin 10 (IL-10) and implantation markers MUC1 and Notch 1 were done on the endometrial samples along with 25 control subjects.ResultsConventional tests for tuberculosis like staining for acid fast bacilli (AFB), granuloma on histology or culture positivity were seen in 2.61% (6/306; 1.96% had granulomas, 1/306; 0.32% was AFB positive, 2/306; 0.6% were liquid culture positive). PCR was positive in 190/306 (62.09%). CD3, CD20, CD45, CD68, CD4, CD8 and CD 138 expressing infiltrating cells were not significantly related to PCR positive cases. Interferon gamma expressing lymphocytes were significantly higher (38.94%) in PCR positive endometria compared to 26.72% in the PCR negative (p = 0.04). Notch ?1 expression correlated significantly with the occurrence of pregnancy. A trend towards high intensity expression of Notch1 was seen in PCR negative cases. MUC-1 expression did not correlate with pregnancy although interferon gamma expression was significantly related to low intensity MUC1 expression.ConclusionsImmunohistochemical markers are not reliable tests in diagnosis of FGTB. Notch 1 expression though showing correlation with pregnancy has to be further evaluated with a panel of other implantation markers.Study fundingIndian Council of Medical Research, New Delhi, India.     

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

AimsTo demonstrate a new laparoscopic sign “Sharma's Parachute sign” in abdominopelvic tuberculosis in women with infertility.MethodsA 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.ResultsThe 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.ConclusionDiagnostic laparoscopy is an important investigation for abdominopelvic tuberculosis showing various adhesions including new parachute sign.     

Correlation of past tuberculosis with current screening for female genital tuberculosis in infertile women in a tertiary care hospital

ObjectivesTo analyse correlation of past history of tuberculosis with present state of infertility with respect to HSG and diagnostic findings, with a view to assess the frequency of genital tuberculosis in infertile women, its clinical presentation and association with infertility.Materials and methodsThe study is an ongoing study conducted in the Department of Obstetrics and Gynaecology, Kasturba Hospital, Delhi and included 174 infertile women enrolled as OPD patients in our hospital. A detailed history with special emphasis on past history of tuberculosis, thorough clinical examination, all routine investigations for Infertility & special investigations for genital tuberculosis was done. Diagnostic tests and laparoscopy was further performed as per the protocol.ResultsFemale genital tuberculosis has been described as a disease of the younger population. The present study shows that 87.9% patients diagnosed for genital tuberculosis were between 20 and 35 yrs of age. It was observed that amongst 174 infertile patients who attended our OPD, 40 patients had a positive history of present or previous incidence of Koch's, pulmonary or extra pulmonary, namely 22.9% (Group I) and the remaining patient comprising 77.1%, who had no record of any previous tuberculosis (Group II). Active Tuberculosis was seen in 5 patients out of a total of 40 females. Out of the total of 174 infertile patients suffering from tubal disorder 52.5% of Group I patients had evidences of tubal disease as compared to only 27.6% in Group II thus suggesting a strong correlation of tubal destruction and subsequent infertility to a positive history of tuberculosis. Out of the 56 laparoscopies performed, it was seen that 75% of Group I patients with past history of TB had abnormal laparoscopic findings (18 out of 24 patients), as compared to Group II which had only 9 out of 32 patients (28%) showing positive pelvic pathology. This seems to be very significant.ConclusionIn conclusion the results of the present study validate arguments in favour of incorporating screening for genital tuberculosis as a part of the baseline investigation for all patients of infertility, in countries like ours and especially in such patients who have suffered from Tuberculosis sometimes earlier in their lives.     

Genital footprints of extragenital tuberculosis in infertile women: Comparison of various diagnostic modalities

BackgroundGenital tuberculosis (TB) continues to remain an important cause of infertility in women, especially in developing countries. It is mostly consequent to a primary infection elsewhere in the body. The diagnosis is challenging, considering its paucibacillary nature. Although there are many studies on association of genital tuberculosis with infertility, there is paucity of literature on impact of extragenital tuberculosis on fertility of women through involvement of female reproductive organs. The various diagnostic modalities available have limitations and quest is ongoing for the best diagnostic test.MethodThis was a prospective observational study conducted at the infertility clinic of a tertiary care health facility where 60 infertile women with either tubal factor or unexplained infertility with or without past history of extragenital tuberculosis were enrolled as study subjects or controls respectively. Mantoux test was performed in all women and diagnostic laparo-hysteroscopy was performed in all women to look for any evidence of uterine and/or tubal damage. The peritoneal fluid was sent for GeneXpert and Liquid culture for mycobacterium tuberculosis. Results of Mantoux test, GeneXpert and liquid culture were compared with the laparohysteroscopic findings.ResultOf the thirty infertile women in the study group, 27/30 (90%) had a history of pulmonary tuberculosis and 3/30 (10%) had history of tubercular cervical lymphadenopathy. It was observed that Mantoux test was positive (induration >10 mm) in 27/30 (90%) of women in the study group as compared to only 4/30 (13.3%) controls. Abnormal hysteroscopic findings were documented in 26.6% (8/30) study group women as compared to 6.6% (2/30) women in the control group. Similarly, 60% (18/30) of women in the study group had abnormal laparoscopic findings compared to 33% (10/30) in the control group. Seven out of thirty (23.3%) women were positive for GeneXpert in the study group compared to only 1/30 (3.3%) in the control group. Similarly, liquid culture was positive in 6/30 (20%) of women in the study group as compared to 1/30 (3.3%) in the control group. All the above differences were statistically significant. We observed that the sensitivity of Mantoux test (75.8%) stand alone was higher than the other tests combined (50%). However, specificity and positive predictive value (PPV) increases markedly (up to 100%) to when all the three tests are combined.ConclusionThe authors conclude that all women presenting with infertility should be screened for a past history of tuberculosis and actively worked up for genital tuberculosis in case the history is positive. The various available tests (Mantoux test, GeneXpert and liquid culture) have their limitations for the diagnosis of genital tuberculosis. Thus an approach of early resort to laparohysteroscopy in suspected patients is desirable so that definitive management may be instituted timely and promptly.     

Is the rise in Crohn's disease in India accompanied by a fall in intestinal tuberculosis? A single-center experience

IntroductionThe relationship between the incidence of intestinal tuberculosis (TB) and Crohn's disease (CD) is interesting, especially considering the striking similarity between the two conditions. Some studies from Asian populations suggested that the incidence of intestinal TB decreases when there is an increase in CD.AimTo compare the incidence trend between intestinal TB and CD over 15 years.MethodsMedical records of patients seen in the Division of Gastroenterology over 15 years (2005–2019) were reviewed. CD was diagnosed according to the Copenhagen criteria. Intestinal TB was diagnosed in the appropriate clinical situation if any one or more of the following was present: (1) positive TB MGIT culture; (2) positive Gene Xpert for TB; (3) suggestive histologic findings, with positive tissue acid-fast bacillus (AFB) on smear or with sustained response to anti-TB therapy. The incidence time trend of patients with CD and intestinal TB diagnosis was then studied year-wise.Results632 medical case records were accessed; 60 patients were excluded due to inadequate data or not fulfilling diagnostic criteria. The 572 patients included 224 with intestinal TB (median age 37 years, IQR 22; 125 [56%] females) and 348 with CD (median age 40 years, IQR 25; 159 [46%] females [p < 0.02 as compared to TB]). Thus, more patients with CD were seen during the study period, but there was no correlation between the incidence of the two conditions (r = 0.318; p = 0.25).ConclusionIn Indian patients in a single private-sector center, there was no inverse correlation between the incidence of intestinal TB and CD over 15 years.     

Detection of genital tuberculosis among women with infertility using best clinical practices in India: An implementation study

BackgroundDiagnosis of genital tuberculosis (TB) as a cause of infertility still remains a diagnostic dilemma for clinicians, as no standard guidelines exist. The recently proposed best practices for genital TB diagnosis have not been evaluated yet in India.ObjectivesTo implement best practices to diagnose and treat likely genital TB as a cause of infertility.MethodsBetween April 2016 and June 2018, consenting women seen at a tertiary hospital infertility clinic were assessed by thorough TB related clinical history, ultrasonography, tuberculin skin test (TST), and ESR. Those with suspected genital TB underwent laparohysteroscopy. Clinical and laboratory characteristics were compared between likely (microbiologically confirmed or probable TB) and unlikely (possible and no genital TB) genital TB. Fertility outcome was assessed among women initiated on anti-TB treatment (ATT).ResultsOf 185 women seeking infertility care, likely genital TB was identified among 29 (15.7%) women, with 6 (21%) confirmed and 23 (79%) probable genital TB. Compared to unlikely genital TB cases, the likely genital TB group were found to have past history of TB (p < 0.001); positive TST (p = 0.002) and elevated ESR (p = 0.001). Among the likely genital TB group, all 6 confirmed genital TB were started on ATT and 2 (33.3%) conceived. Of 5 probable genital TB started on ATT, 3 (60%) conceived.ConclusionApproximately 1/6th of women seeking infertility care met the criteria for likely genital TB. Conception among over-half of treated probable genital TB cases provides preliminary evidence that best clinical practices can be utilized, but needs further confirmatory studies.     

Cartridge based nucleic acid amplification test is superior in diagnosing lymphnode tuberculosis

BackgroundThe role of Cartridge based Nucleic Acid Amplification test (CBNAAT) in the diagnosis of lymphnode TB which helps in reducing the mortality and morbidity by early identification and initiating treatment at the earliest. Also helps in identify the drug resistance among tubercular lymphnodes cases.Patients and methodsA prospective clinical study was performed in 101 suspected lymph node tuberculosis patients. The results of FNAC and/or excision biopsy of lymphnode samples obtained by CBNAAT were compared with direct smear microscopy for AFB bacilli, cytology and their combination considering AFB culture as gold standard.ResultsA total of 101 patients were evaluated of which 74 subjects (73.3%) were CBNAAT positive for TB. Among the CBNAAT positive cases, 57 were aged above 16 years, 38 were females, equal number (37) had single and multiple lymphnodes, 46 had less than 1 cm size lymphnodes, 69 had lymphnode in neck region, 65 had chest X-ray normal. Among CBNAAT positive 74 subjects, 53 subjects (71.6%) were positive for AFB direct smear, 64 subjects (86.48%) were cytology consistent with TB and their combination were positive for TB in 71 subjects (95.94%) and 71 subjects (95.94%) were positive by AFB culture and 3 cases (0.04%) showed Rifampicin resistance.ConclusionCBNAAT is a rapid diagnostic tool having sensitivity of 93.42% with specificity of 86.96% and positive predictive value of 95.95% and having comparable results with AFB culture and more sensitive than other investigation procedures. Thus it can be a rule in test for lymphnode TB.     

Importance of eosinophilic structures and its correlation with acid fast bacilli in fine needle aspiration smears of tubercular lymphadenitis

BackgroundThe hallmark of tuberculosis in cytological smears is the presence of epithelioid cell granulomas, necrosis and AFB. In cases, where AFB not detected, diagnosis of tuberculosis can be made by ancillary tests like PCR which requires infrastructure besides being expensive. In India, where majority of population is rural-based there is an imminent need of some morphological change in cytological smears which can point towards diagnosis of tuberculosis in absence of AFB. This study was done to assess the importance of eosinophilic structures (ES) and its correlation with presence of AFB.Material & methodsThis was a retrospective study over a period of one year. Lymph node aspirates reported as granulomatous lymphadenitis, tubercular lesion or suppurative lesion were included. All smears for each case, stained with May Grunwald Giemsa (MGG), Hematoxylin and Eosin (H&E) and ZN stain were retrieved and rescreened for the presence of eosinophilic structure, necrosis, granulomas and AFB.ResultsOur study included 256 cases. Most common age group was 21–30 years with female predominance. Cervical lymph nodes were most commonly involved. In relation to ES and AFB four cytological pictures were seen i.e ES + AFB+ (44.54%) ES + AFB- (5.46%) ES- AFB+ (14.45%) ES - AFB- (35.55%). Chi square test showed a high significant statistical association between ES and AFB(p = 0.00001).ConclusionIn developing countries with very high TB prevalence like India, where new diagnostic modalities are unaffordable by rural population, presence of ES should be included as a morphological parameter in routine cytology reporting of tubercular lesions.     

Interferon-Gamma Release Assay in the Ascites: Early Hint for Diagnosis of Abdominal Tuberculosis

We report on a 20-year-old woman with abdominal tuberculosis.Standard microbiological examination of ascites showedno acid-fast bacilli (AFB), and analysis for the Mycobacteriumtuberculosis (MTB)-complex DNA by PCR was negative. However,the interferon-γ release assay (IGRA) of the ascites waspositive after specific stimulation with mycobacterial antigens(ESAT-6/CFP-10/TB7.7[p4]), indicating an infection with MTB.The diagnosis of tuberculosis was later confirmed by histology,MTB culture, and PCR analysis of MTB-complex DNA in tissuesamples taken during laparoscopy. Thus, the IGRA of ascitesmay guide the decision to start active treatment for tuberculosis.     

Utility of RNTCP (NTEP) guidelines in microbiological confirmation of pediatric tuberculosis

ObjectiveTo estimate the proportion of microbiologically confirmed disease among children diagnosed with tuberculosis using RNTCP guidelines.Materials and methodsRetrospective chart review of a cohort of 151 children (aged between 1 month and 18 years) diagnosed with Tuberculosis between December 2016 and June 2020 at a pediatric department of a tertiary care hospital. We collected information on AFB (Acid Fast Bacillus) smear and Cartridge Based Nucleic Acid Amplification Test (CB NAAT) results.ResultsOut of 151 children with a diagnosis of Tuberculosis, 66 (44%) children were found to have microbiologically confirmed disease. Confirmatory rate was almost equal in children less than <5 and >5 years (48% vs 52%). Confirmatory rate did not differ between pulmonary and extra pulmonary samples (49% and 53%). Cartridge Based Nucleic Acid Amplification Test outperformed AFB by 10%, which was statistically significant (p = .000 by fisher exact test).ConclusionAlthough considered paucibacillary in nature, microbiological confirmation can be obtained in almost up to half of children with a diagnosis of TB by using RNTCP guidelines. Neither young age nor type of TB is a deterrent to bacteriologically confirm TB in children.     

Utility of Fine Needle Aspiration Cytology (FNAC) in the diagnosis of tuberculous lymphadenitis compared to GeneXpert in a tertiary health care center in Northern Odisha,India

BackgroundDiagnosis of extrapulmonary tuberculosis including tuberculous lymphadenitis (TBLN) is challenging because of its atypical clinical presentation, paucibacillary nature of mycobacteria at the infected sites, variation in sensitivity of a test to specimens collected by different methods and from different infected tissues.MethodsIn the present study, suspected individuals for lymph node tuberculosis irrespective of age were enrolled prospectively and specimens were collected aseptically by fine needle aspiration (FNA). After the implementation of exclusion criteria, FNA specimens from a total of 278 cases of suspected TBLN were evaluated for cytomorphology (FNAC), presence of acid-fast bacillus (AFB) in smear microscopy and specific detection of mycobacterial DNA in cartridge-based nucleic acid amplification test (CBNAAT).ResultsThe results showed high prevalence of Type II (59.71%), followed by Type I (34.53%) and Type III (5.75%) pattern in FNAC. Non-type II patterns were significantly high in regions outside of the head and neck region (P = 0.031; OR = 2.125) and had an increasing trend of their occurrences with progression of age. The most affected age group was between 16 and 30 years with female preponderance documented in individuals below 45 years, whereas male preponderance was observed in higher age group patients, majority of whom had infected lymph nodes outside of HAN region (P = 0.063, OR = 1.998). The results also showed high sensitivity of CBNAAT (83.04%) method followed by FNAC (72.17%) with AFB smear exhibiting the disappointing results (sensitivity of 10.86%) compared to the CRS. High percentage of positivity was observed in Type III (AFB:25% vs CBNAAT: 100%) followed by Type II (AFB:10.2 vs CBNAAT: 76.5), while low detection was observed from samples with Type I (AFB:4.2 vs CBNAAT: 50). Interestingly, CBNAAT detection of TB was shown to be unaffected by gender, age and site of infection.ConclusionThe study suggests a possible contributary role of age and gender for cytomorphological pattern distribution of TBLN at various body parts. Although FNAC detected TB in 77.1% of cases which were identified positive by CBNAAT and/or AFB, it is being solely based on cytomorphology cannot be used alone as a reliable diagnostic method for TBLN detection. Further, the negative results in CBNAAT for FNAC positive cases may not necessarily be non-TB cases and must be evaluated by other diagnostic modalities. We recommend for both cytomorphological investigation and CBNNAT for the fine needle aspirates from suspected TBLN and subsequent treatment to reduce the disease burden.     

Role of Magnetic Resonance Imaging in evaluation of tuberculous tubo ovarian mass

ObjectiveRole of Magnetic Resonance Imaging (MRI) in diagnosis of tuberculous tubo-ovarian (TO) mass.MethodsMRI was performed on 33 patients of tuberculous TO mass of female genital tuberculosis (FGTB).ResultsMean age, BMI, and parity was 27.5 ± 4.2 years, 22.7 ± 3.6 kg/m², and 0.27 ± 0.13. All patients (100%) had infertility; primary infertility (72.72%) and secondary infertility (27.23%) with mean 5.8 years. Abdominal/pelvic pain 33 (100%) cases, abdominal lump 4 (12.12%), adnexal mass 33 (100%). MRI findings showed pelvic masses 33 (100%), bilateral TO masses 11 (33.33%), cystic lesion 4 (12.12%), solid cystic lesion 3 (9.09%) with bilateral pyosalpinx 1 (3.3%), homogeneous content with ascites 1 (3.03%), rim enhancing lesion abutting pelvic wall in 1 (3.03%). Right adnexal mass 11 (33.33%), right adnexal cyst 2 (6.06%), right adnexal cystic mass in 1 (3.03%), right sided complex TO mass 1 (3.03%), right sided hydrosalpinx in 1 (3.03%) case, right sided TO mass in 4 (12.12%) cases and right sided para-ovarian cyst in 2 (6.06%). Left sided adnexal mass was seen in 11 (33.33%), cystic lesion in 1 (3.03%), ovarian cyst in 3 (9.09%) cases, left sided hydrosalpinx in 2 (6.06%), left ovarian cyst 2 (6.06%) cases, left sided ovarian cyst with encysted ascites 1 (3.03%) case and with left sided paraovarian cyst 2 (6.06%) case. Miscellaneous finding were generalised ascites (6.06%), encysted ascites (3.03%), pelvic (1; 3.03%) and mesenteric lymphadenopathy 1 (3.03%). Incidental finding were fibroid 3 (9.09%) and adenomyosis 1 (3.03%) case.ConclusionMRI appears to be useful diagnostic modality for tuberculous TO masses where differential diagnosis is malignancy but molecular diagnosis remains the gold standard.     

Prospective study of SEVA TB peroxidase assay for cocktail antigen and antibody in the diagnosis of Tuberculosis in suspected patients attending a tertiary care hospital located in rural area

ObjectiveTo evaluate inhouse developed SEVA TB peroxidase enzyme immunoassay using cocktail of mycobacterial excretory-secretory antigens (ES-31, ES-43 & EST-6) for antibody detection and their affinity purified antibodies for antigen detection in tuberculosis suspected patients.MethodsInhouse developed SEVA TB peroxidase enzyme immunoassay was evaluated prospectively in 73 suspected pulmonary and 46 extra-pulmonary tuberculosis patients during November 2008～March 2009 in a tertiary hospital located in rural area.ResultsAssay on prospective analysis showed 100% correlation of pulmonary tuberculosis (PTB) and extra-pulmonary tuberculosis (EPTB) acid fast bacilli positivity and antitubercular treatment in 11 cases. Thirty nine PTB and 12 EPTB cases showed negative for ELISA test and were also not given antitubercular therapy. However 30 PTB and 27 EPTB cases showing ELISA positivity were neither acid fast bacilli positive nor antitubercular therapy treated. These cases may possibly have dormant infection and need further diagnosis. In EPTB cases ELISA was observed to be more useful than AFB smear test.ConclusionsThis inhouse developed user-friendly peroxidase ELISA can be used as an adjunct test of smear microscopy or culture techniques for routine screening of patients suspected of PTB or EPTB.     

The clinician,the lab and the patient: Understanding lab diagnostics to eradicate tuberculosis

BackgroundDiagnostic modalities for diagnosing Tuberculosis caused by Mycobacterium group of organisms include mainly AFB smear by Ziehl Neelsen carbol fuchsin smear microscopy, GeneXpert (CB NAAT) molecular method, Line probe assay (Molecular method) and AFB culture (Liquid automated systems and solid media) methods.MethodsThis study was initiated to understand and prioritize TB lab diagnosis, with reference to selection of lab diagnostic tests and its order of preference for MTC and NTM/MOTT closely associating it with the TB irradication program initiated by the Government of India.Result and conclusionThe results and discussion bring to light the importance of each test and the purpose of their requisition. When diagnosis is handled half heartedly eradication of TB becomes a challenge. All the efforts including planning, resources in the form of manpower, infrastructure, finances, education, time etc., would be hampered. This challenge is not only for India but the globe. For countries harboring TB, Correct diagnostic request and timely diagnosis and treatment is the key to eradication of tuberculosis.     

Impact of pulmonary tuberculosis on menstrual pattern and fertility

Introduction and Study Objective: The association between pulmonary tuberculosis (TB) and female reproductive health problems is not well addressed. This study was done at Assiut University and Woman's Health University Hospitals to estimate the effect of pulmonary TB on menstrual patterns and fertility of women in childbearing age. Patients and Methods: This study composed of 429 women with pulmonary TB of childbearing age (study group) and 100 age‐matched healthy women (control group). A detailed medical history was obtained, and a clinical examination, routine investigations of pulmonary TB and transvaginal ultrasonography (TVS) were performed for all cases. Hysterosalpingography, combined laparoscopy and hysteroscopy were done for infertile women whenever indicated. Results: Menstrual abnormalities were reported in 66% of women in the study group. Secondary amenorrhea (112 cases, 26.5%, P < 0.001) and hypomenorrhea (86 cases, 20%, P < 0.001) were significantly higher in the study group than controls (2% and 3%, respectively). TVS diagnosed functional ovarian cysts in 85 patients in the study group (19.8%). After completing anti‐tuberculosis treatment, 76% of women with menstrual abnormalities (162/213) resumed normal menstrual cycles. Among the 68 cases who sought fertility within 1 year after completion of treatment, TB peritubal and fine intrauterine adhesions were confirmed by laparoscopy and hysteroscopy in two and one infertile woman, respectively (0.7% of study group). Conclusions: TB had marked reversible effect on the menstrual cycle but minimal association with genital TB and infertility. Pretreatment counseling of pulmonary TB women should include information on these reversible changes. Persistence of menstrual abnormalities or presence of infertility after completion of treatment should stimulate investigation for the possibility of genital tract involvement. Please cite this paper as: Hassan WA and Darwish AM. Impact of pulmonary tuberculosis on menstrual pattern and fertility. The Clinical Respiratory Journal 2010; 4: 157–161.     

Clinical significance of normal chest radiographs among HIV-seropositive patients with suspected tuberculosis in Uganda

Background and objective: The frequency, aetiologies and outcomes of normal chest radiographs (CXRs) among HIV‐seropositive patients with suspected pulmonary tuberculosis (TB) have been infrequently described. Methods: Consecutive HIV‐seropositive adults hospitalized for cough of ≥2 weeks duration at Mulago Hospital (Kampala, Uganda), between September 2007 and July 2008, were enrolled. Baseline CXRs were obtained on admission. Patients with sputum smears that were negative for acid‐fast bacilli (AFB) were referred for bronchoscopy with bronchoalveolar lavage (BAL). BAL fluid was examined for mycobacteria, Pneumocystis jirovecii and other fungi. Patients were followed for 2 months after enrolment. Results: Of the 334 patients, 54 (16%) had normal CXRs. These patients were younger (median age 30 vs 34 years, P = 0.002), had lower counts of CD4+ T lymphocytes (median 13 vs 57 cells/µL, P < 0.001), and were less likely to be smear positive for AFB (17% vs 39%, P = 0.002) than those with abnormal CXRs. Pulmonary TB was the most frequent diagnosis (44%) among those with normal CXRs, followed by unknown diagnoses, pulmonary aspergillosis and pulmonary cryptococcosis. The frequency of normal CXRs was 12% among pulmonary TB patients. There was a trend towards increased 2‐month mortality among patients with normal CXRs compared to those with abnormal CXRs (40% vs 29%, P = 0.15). Conclusions: Normal CXR findings were common among HIV‐seropositive patients with suspected TB, especially those who were young, those with low CD4+ T cell counts and those with sputum smears that were negative for AFB. Mortality was high among those with normal CXRs. Normal CXR findings should not preclude further diagnostic evaluation in this population.     

Acid-fast bacilli culture positivity and drug resistance in abdominal tuberculosis in Mumbai,India

Background and Aim

Culture positivity for Mycobacterium tuberculosis complex (MTB) in abdominal tuberculosis (TB) using Lowenstein Jensen medium and Bactec system varies from 25 % to 36 %. Data on the prevalence of drug resistance in primary abdominal TB is scant. Our aim was to study the acid-fast bacilli (AFB) culture positivity rate in primary abdominal TB using Bactec Mycobacterial Growth Indicator Tubes (MGIT) system and the prevalence of drug resistance in these patients.

Method

Records of patients with abdominal TB (diagnosed on clinical features, endoscopy, histology, microbiology) seen during the period 2008 to 2013 were retrieved from the Gastroenterology and Microbiology departments. Patients with extra-abdominal TB (five pulmonary, two nodal), adnexal (one), and HIV (one) were excluded from analysis.

Results

Of 61 patients, 31 (50.8 %) had a positive AFB culture. In the 30 culture-negative patients, histology showed non-caseating granulomas in 25 patients. Drug sensitivity pattern was analyzed in 18 patients; resistance was detected in eight (14.3 % of all patients and 44.4 % of patients in whom drug sensitivity was done) including three (5.4 % of all subjects and 16.6 % in whom drug sensitivity was available) who were multidrug-resistant.

Conclusions

The rate of AFB culture positivity in primary abdominal TB was 50.8 % using Bactec MGIT. Likelihood of drug resistance was seen in 14.3 %, of whom 5.4 % were multidrug-resistant.     

Factors associated with treatment outcome in 64 HIV negative patients with multidrug resistant tuberculosis

Objectives

In this study we aimed to determine the factors associated with treatment outcome in HIV negative patients with multidrug resistant tuberculosis (MDR TB).

Materials and methods

The study comprised 64 (43 female and 21 male) patients in whom second line TB drugs were administered in directly observed treatment (DOT) programme. Achievement of sputum AFB (acid fast bacilli) negativity in the 3rd month of the treatment was accepted as the bacteriologic response. Treatment outcome of the patients and the factors influencing the bacteriologic response were evaluated.

Results

The mean time of sputum smear negativity was determined as 3±2.2 months. Bacteriologic response was determined in 73.4% of the patients. The mean duration time of the treatment was 16.4±8.2 months. Treatment outcome of the patients was determined as cure in 34 (53.1%), default in 18 (28.1%), treatment failure in 1 (1.6%) and exitus in 3 (4.7%) patients. Also, in 8 (12.5%) patients treatment was incomplete and continued. Adverse effects of the drugs were seen in 39 (60.9%) patients with the most frequency of gastrointestinal disturbance (51.5%), psychiatric disorders (15.6%), dermatological effects (12.5%). In logistic regression analysis only presence of cavity and the extensive disease were found to be associated with poor bacteriologic response (OR=1.5, 95% CI: 1.23-1.82, P=0.01 and OR=2, 95% CI: 1.42-2.79, P=0.00, respectively).

Conclusions

Although radiological findings might affect the bacteriologic response, MDR TB is a treatable disease if regular and appropriate treatment regimen is administered.KEY WORDS : Multidrug resistant tuberculosis (MDR TB), treatment, outcome