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Sharma JB, Jain S, Dharmendra S, Singh UB, Soneja M, Kulshrestha V, Vanamail P. An evaluation of Composite Reference Standard (CRS) for diagnosis of Female Genital Tuberculosis. Indian J Tuberc 2023; 70:70-76. [PMID: 36740321 DOI: 10.1016/j.ijtb.2022.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 08/06/2021] [Accepted: 03/09/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Female 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. METHODS This 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. RESULTS A 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. CONCLUSION This study demonstrates the high reliability of use of composite reference standard for diagnosis of FGTB.
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Affiliation(s)
- J B Sharma
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi, India.
| | - Shefali Jain
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi, India
| | - Sona Dharmendra
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi, India
| | - Urvashi B Singh
- Department of Microbiology, All India Institute of Medical Sciences, New Delhi, India
| | - Manish Soneja
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Vidushi Kulshrestha
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi, India
| | - P Vanamail
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi, India
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Tzelios C, Neuhausser WM, Ryley D, Vo N, Hurtado RM, Nathavitharana RR. Female Genital Tuberculosis. Open Forum Infect Dis 2022; 9:ofac543. [PMID: 36447614 PMCID: PMC9697622 DOI: 10.1093/ofid/ofac543] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 10/20/2022] [Indexed: 06/21/2024] Open
Abstract
Female genital tuberculosis (FGTB) is an important cause of morbidity and infertility worldwide. Mycobacterium tuberculosis most commonly spreads to the genital tract from a focus elsewhere in the body and affects the bilateral fallopian tubes and/or endometrium. Many patients with FGTB have indolent disease and are only diagnosed after evaluation for infertility. Women may present with menstrual irregularities, lower abdominal or pelvic pain, or abnormal vaginal discharge. Given the low sensitivity of diagnostic tests, various composite reference standards are used to diagnose FGTB, including some combination of endoscopic findings, microbiological or molecular testing, and histopathological evidence in gynecological specimens. Early treatment with a standard regimen of a 2-month intensive phase with isoniazid, rifampin, ethambutol, and pyrazinamide, followed by a 4-month continuation phase with isoniazid and rifampin, is recommended to prevent irreversible organ damage. However, even with treatment, FGTB can lead to infertility or pregnancy-related complications, and stigma is pervasive.
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Affiliation(s)
- Christine Tzelios
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Werner M Neuhausser
- Division of Reproductive Endocrinology and Infertility, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
| | - David Ryley
- Division of Reproductive Endocrinology and Infertility, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
- Boston IVF, Boston, Massachusetts, USA
| | - Nhi Vo
- Division of Radiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Rocio M Hurtado
- Division of Infectious Diseases, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Ruvandhi R Nathavitharana
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
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Sidiq Z, Hanif M, Dwivedi KK, Chopra KK, Khanna A, Vashishat BK. Effectiveness of Xpert MTB/RIF for the diagnosis of extrapulmonary tuberculosis at various stand-alone laboratories in Delhi. Indian J Tuberc 2022; 69:530-534. [PMID: 36460384 DOI: 10.1016/j.ijtb.2021.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 08/09/2021] [Indexed: 06/17/2023]
Abstract
BACKGROUND Globally, EPTB accounts for 15% of the notified incident TB cases. Laboratory confirmation of EPTB is challenging and majority of the cases remain undetected for a longer time. A major breakthrough in the diagnosis of EPTB was the introduction of nucleic acid amplification tests (NAAT). One such test-the Xpert MTB/RIF assay also known as Cartridge based nucleic acid amplification test (CBNAAT) was endorsed by the Scientific and Technical Advisory Board of the WHO for the diagnosis of Tuberculosis. The present study was conduct to evaluate the outcome of various extrapulmonary samples tested in the year 2019 at different standalone NAAT laboratories in Delhi. MATERIALS AND METHODS A total of 20,238 samples consisting mainly of Pus (21.77%), Cerebrospinal fluid (CSF) (14.96%), Biopsies (13.87%), Pleural fluid (10.49%), Lymph node aspirations (FNAC aspirates) (6.75%), synovial fluid (0.54%) and gastric aspirates (26.4%) tested at 22 standalone NAAT laboratories were included in this study. RESULTS Mycobacterium tuberculosis was detected in 3496 samples and resistance to rifampicin was detected in 329 of the samples. The overall yield of all the specimens combined was 17.2%. Highest yield was seen in Lymph nodes aspirates (FNAC) (36.0%), followed by pus (35.4%), tissues (15.7%), synovial fluid (13.5%), Endometrial tissues (10.7%), Pleural fluid (9.5%), Gastric aspirates (9.4%) and CSF (6.5%). The lowest yield was seen in Cavitary fluids (6.2%). CONCLUSION The results of this study highlight the usefulness of Xpert MTB/RIF assay in the diagnosis of EPTB. In particular, this assay proved to be of great utility while testing pus samples, tissue samples and lymph node FNACs.
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Affiliation(s)
- Zeeshan Sidiq
- New Delhi Tuberculosis Centre, Jawaharlal Nehru Marg, Delhi Gate, New Delhi, 110002, India
| | - M Hanif
- New Delhi Tuberculosis Centre, Jawaharlal Nehru Marg, Delhi Gate, New Delhi, 110002, India.
| | - Kaushal Kumar Dwivedi
- New Delhi Tuberculosis Centre, Jawaharlal Nehru Marg, Delhi Gate, New Delhi, 110002, India
| | - Kamal Kishore Chopra
- New Delhi Tuberculosis Centre, Jawaharlal Nehru Marg, Delhi Gate, New Delhi, 110002, India
| | - Ashwani Khanna
- State TB Cell, NTEP Delhi, Health Centre Building, Delhi Government Colony, Gulabi Bagh, Delhi, 110007, India
| | - B K Vashishat
- State TB Cell, NTEP Delhi, Health Centre Building, Delhi Government Colony, Gulabi Bagh, Delhi, 110007, India
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Sharma JB, Singh UB, Kriplani A, Kumar S, Roy KK, Kumari A, Dharmendra S. Hysteroscopic observations in 348 consecutive cases of female genital tuberculosis: A prospective study. Indian J Tuberc 2022; 69:48-57. [PMID: 35074151 DOI: 10.1016/j.ijtb.2021.02.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 12/29/2020] [Accepted: 02/19/2021] [Indexed: 06/14/2023]
Abstract
STUDY OBJECTIVE To evaluate the hysteroscopic findings in female genital tuberculosis. DESIGN It was a prospective study of hysteroscopic findings performed on 348 cases of female genital tuberculosis (FGTB). SETTING It was a prospective cross-sectional study in a tertiary referral centre. PATIENTS A total of 348 patients with infertility with FGTB on various tests. INTERVENTION A total of 348 patients of infertility found to have FGTB on various investigations were enrolled in the study. A detailed history was taken. Clinical examination, endometrial sampling and diagnostic laparoscopy were performed was also performed in selected cases. All patients underwent hysteroscopy as part of evaluation for infertility and tuberculosis (TB) findings. MEASUREMENTS AND MAIN RESULTS The mean age, parity, body mass index and duration of infertility was 28.2 years, 0.31,23.1kg/m2 and 3.44 years respectively. Infertility was primary in 81.03% and secondary in 18.96% cases. Diagnosis of FGTB was made by endometrial aspirate findings of positive AFB on microscopy (4.02%), positive culture (4.88%), positive PCR (83.90%), epithelioid granuloma (14.65%), positive AFB on microscopy or culture of peritoneal cytology (1.14%) or epithelioid granuloma on peritoneal biopsy (1.72%), definitive findings of TB on laparoscopy (41.95%) or probable findings of TB on laparoscopy (58.05%). Various hysteroscopic findings observed were normal findings (28.16%), pale endometrial cavity (54.31%), features of active TB (7.47%), features of chronic TB (19.54%), features of TB sequelae like obstructed ostia (both ostia in 13.79%, one ostia 14.94%, periostial fibrosis; (bilateral 4.59%, unilateral 5.17%), endometrial glands atrophy (12.35%), small shrunken cavity (6.32%), distorted cavity (5.17%), various grades of intrauterine adhesions (29.88%). Hysteroscopy in FGTB was associated with increased difficulties and complications like failed procedures, difficult visualisation, false passage and uterine perforation. CONCLUSION Hysteroscopy is useful modality to detect endometrial TB but is associated with increased difficulty and complications.
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Affiliation(s)
| | | | - Alka Kriplani
- Department of Obstetrics and Gynaecology, AIIMS, New Delhi, India
| | - Sunesh Kumar
- Department of Obstetrics and Gynaecology, AIIMS, New Delhi, India
| | - Kallol Kumar Roy
- Department of Obstetrics and Gynaecology, AIIMS, New Delhi, India
| | - Anukriti Kumari
- Department of Obstetrics and Gynaecology, AIIMS, New Delhi, India
| | - Sona Dharmendra
- Department of Obstetrics and Gynaecology, AIIMS, New Delhi, India
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Sharma JB, Manchanda S, Jaiswal P, Dharmendra S, Singh U, Hari S. Computed tomographic findings in female genital tuberculosis tubo-ovarian masses. Indian J Tuberc 2022; 69:58-64. [PMID: 35074152 DOI: 10.1016/j.ijtb.2021.03.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 03/02/2021] [Indexed: 06/14/2023]
Abstract
UNLABELLED 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.
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Affiliation(s)
| | | | - Parul Jaiswal
- Department of Obstetrics and Gynaecology, AIIMS, New Delhi, India
| | - Sona Dharmendra
- Department of Obstetrics and Gynaecology, AIIMS, New Delhi, India
| | | | - Smriti Hari
- Department of Radio Diagnosis, AIIMS, New Delhi, India
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Dahiya B, Kamra E, Alam D, Chauhan M, Mehta PK. Insight into diagnosis of female genital tuberculosis. Expert Rev Mol Diagn 2021; 22:625-642. [PMID: 34882522 DOI: 10.1080/14737159.2022.2016395] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Female genital tuberculosis (TB) is a common manifestation of extrapulmonary TB (EPTB) with varied clinical presentations, i.e. infertility, pelvic pain and menstrual irregularities. Diagnosis of female genital TB is challenging predominantly due to paucibacillary nature of specimens and inconclusive results obtained by most of the routine laboratory tests. AREAS COVERED This review has briefly summarized the epidemiology, clinical features and transmission of female genital TB. Commonly used laboratory tests include bacteriological examination (smear/culture), tuberculin skin testing, interferon-γ release assays, imaging, laparoscopy/hysteroscopy and histopathological/cytological observations. Further, utility of nucleic acid amplification tests (NAATs), like loop-mediated isothermal amplification, PCR, multiplex-PCR, nested PCR, real-time PCR and GeneXpert® could significantly improve the detection of female genital TB. EXPERT OPINION Currently, there is no single test available for the efficient diagnosis of female genital TB, rather a combination of tests is being employed, which yields moderate diagnostic accuracy. The latest modalities developed for diagnosing pulmonary TB and other clinical EPTB forms, i.e. aptamer-linked immobilized sorbent assay, immuno-PCR (I-PCR), analysis of circulating cell-free DNA by NAATs, and identification of Mycobacterium tuberculosis biomarkers within extracellular vesicles of bodily fluids by I-PCR/nanoparticle-based I-PCR, may also be exploited to further improve the diagnosis of female genital TB.
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Affiliation(s)
- Bhawna Dahiya
- Centre for Biotechnology, Maharshi Dayanand University, Rohtak-124001, Haryana, India
| | - Ekta Kamra
- Centre for Biotechnology, Maharshi Dayanand University, Rohtak-124001, Haryana, India
| | - Danish Alam
- Centre for Biotechnology, Maharshi Dayanand University, Rohtak-124001, Haryana, India
| | - Meenakshi Chauhan
- Dept. of Obstetrics and Gynecology, Pt. B.D. Sharma University of Health Sciences, Rohtak-124001, Haryana, India
| | - Promod K Mehta
- Centre for Biotechnology, Maharshi Dayanand University, Rohtak-124001, Haryana, India
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Sharma JB, Khurana A, Hari S, Singh U, RituYadav, Dharmendra S. Evaluation of Role of Transabdominal and Transvaginal Ultrasound in Diagnosis of Female Genital Tuberculosis. J Hum Reprod Sci 2021; 14:250-259. [PMID: 34759614 PMCID: PMC8527078 DOI: 10.4103/jhrs.jhrs_161_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Revised: 08/27/2021] [Accepted: 09/09/2021] [Indexed: 11/06/2022] Open
Abstract
Background: Female genital tuberculosis (FGTB) is a common problem in developing countries causing significant morbidity, especially infertility. Radiological imaging, especially ultrasound, can help in diagnosis of FGTB with tubo-ovarian masses. Aims: The present study was performed to evaluate the role of ultrasound in diagnosis of FGTB and to see various findings of FGTB on ultrasound. Study Setting and Design: It was a prospective cross-sectional study over 4-year period between August 2015 and August 2019 in a tertiary referral center. Subjects and Methods: One hundred and seventy-five patients of infertility diagnosed to have FGTB on composite reference standard (CRS) of positive acid-fast bacilli on microscopy or culture of endometrial biopsy, positive polymerase chain reaction, positive GeneXpert, epithelioid granuloma on histology of endometrial biopsy, or definite or probable finding of FGTB on laparoscopy were subjected to transvaginal ultrasound by an experienced sonographer for various findings of FGTB. Statistical Analysis: Data analysis was carried out using STATA software 12.0. Comparison of categorical values was tested using Chi-square Fisher's exact test, with P < 0.05 being taken as significant. Results: Mean age, body mass index, parity, and duration of infertility were 28.9 years, 22.9 kg/m2, 0.26, and 6.06 years, respectively. Menstrual dysfunction was common (44%). Diagnosis of FGTB was made by CRS. Ultrasound was normal in 112 (64%) cases and was abnormal in 63 (36%) cases. Various ultrasound findings were ovarian cyst (23.42%), tubo-ovarian masses (15.42%), unilateral or bilateral hydrosalpinx (13.71%), pyosalpinx (0.57%), adhesion (1.14%), adnexal fixity (6.28%), thin endometrium (24.57%), endometrial fluid (12.57%), endometrial calcification (1.7%), endometrial synechiae (4.57%), cornual synechiae (2.28%), impaired endometrial vascularity (21.71%), ascites (6.85%), and peritoneal or omental thickening (1.75%). Conclusion: Carefully performed ultrasound is a useful modality in diagnosis of FGTB, especially in adnexal masses.
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Affiliation(s)
- Jai Bhagwan Sharma
- Professor, Department of obstetrics and Gynaecology, AIIMS, New Delhi, India
| | - Ashok Khurana
- Consultant Radiology and Ultrasonologist, AIIMS, New Delhi, India
| | - Smriti Hari
- Professor, Department of Radiodiagnosis, AIIMS, New Delhi, India
| | - Urvashi Singh
- Professor, Department of Microbiology, AIIMS, New Delhi, India
| | - RituYadav
- Senior Resident, Department of Obstetrics and Gynaecology, AIIMS, New Delhi, India
| | - Sona Dharmendra
- PhD Scholar, Department of obstetrics and Gynaecology, AIIMS, New Delhi, India
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Sharma JB, Kumar R, Singh U, Kumari A, Dharmendra S, Sachani H. Pre treatment and post treatment positron emission tomography-computed tomography (PET-CT) to evaluate treatment response in tuberculous Tubo-Ovarian masses. Eur J Obstet Gynecol Reprod Biol 2021; 264:128-134. [PMID: 34303072 DOI: 10.1016/j.ejogrb.2021.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 07/05/2021] [Accepted: 07/06/2021] [Indexed: 11/18/2022]
Abstract
PURPOSE Female genital Tuberculosis (FGTB) causes infertility and formation of Tubo-ovarian (TO) masses. The study showed treatment response of PET-CT in evaluation of anti-tubercular treatment response in patients of infertility with tuberculous TO masses. METHOD It's a Prospective study on 47 confirmed cases of FGTB with infertility having TO masses. All patients were subjected to 18F-FDGPET/CT to see the glucose uptake by the TO mass and extent of the disease. Category I treatment under DOTS was given for 6 months. All underwent follow-up of PET/CT to see the response to ATT. Results of pre ATT PET/CT were compared with post ATT PET/CT. RESULTS TO masses was in 42 (89.36%); bilateral in 18 (38.29%) FDG uptake in 14 (29.78%) and without FDG uptake in 4 (8.51%) cases. Right sided mass in 13 (27.65%) FDG uptake in 9 (19.14%) and without FDG uptake in 4 (8.51%) cases. Left sided mass in 11 (23.40%) FDG uptake in 7 (14.89%) and without FDG uptake in 4 (8.51%) cases. Post ATT, there was significant decrease in most parameters. Repeat PET-CT done in 44 cases showed TO mass in 9 (20.45%); bilateral in 4 (9.09%) (FDG uptake in 2.27%) (p < 0.001), right sided in 3 (6.85%) (FDG uptake in 2.27%) (p < 0.002) and left side in 2 (2.27%) FDG uptake in 1 case (p < 0.004). Pelvic and mesenteric lymphadenopathy without FDG uptake was in 1 case (p value = 0.03) while omental and peritoneal deposits without FDG uptake in 1 and 2 cases, respectively. CONCLUSION PET-CT is useful in treatment response evaluation of tubercular TO masses.
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Affiliation(s)
- J B Sharma
- Department of Obstetrics and Gynaecology, AIIMS, Delhi, India.
| | - Rakesh Kumar
- Department of Nuclear Medicine, AIIMS, Delhi, India
| | | | - Anukriti Kumari
- Department of Obstetrics and Gynaecology, AIIMS, Delhi, India
| | - Sona Dharmendra
- Department of Obstetrics and Gynaecology, AIIMS, Delhi, India
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Sharma JB. Sharma's parachute sign a new laparoscopic sign in abdomino pelvic tuberculosis. ACTA ACUST UNITED AC 2021; 68:389-395. [DOI: 10.1016/j.ijtb.2019.06.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 06/15/2019] [Indexed: 10/26/2022]
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Agrawal S, Kant S, Das V, Jain A, Mishra S. Limited role of GeneXpert in peritoneal fluid in the diagnosis of genital tuberculosis in infertile women. J Family Med Prim Care 2021; 10:1656-1660. [PMID: 34123908 PMCID: PMC8144761 DOI: 10.4103/jfmpc.jfmpc_1957_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 12/05/2020] [Accepted: 01/01/2021] [Indexed: 11/26/2022] Open
Abstract
Background and Objectives: Genital tuberculosis (TB) is an important cause of infertility in women that poses many challenges in diagnosis. The study is done to understand the utility of GeneXpert test in peritoneal fluid in the diagnosis of genital TB in infertile women. Methods: All infertile women in postmenstrual phase who were planned for laparoscopy in study period were included. Women who were already on anti-TB therapy were excluded. Peritoneal fluid/washings were retrieved during laparoscopy to test for Mycobacterium tuberculosis by GeneXpert. A note was made of laparoscopy evidence of TB. Endometrial sample was sent for microbiological testing of mycobacterium on smear and liquid culture. Histopathological test of endometrium was also done to look for granulomas. Results: In a total of 57 women, 8 (14.03%) women were diagnosed with TB on the basis of laparoscopy or microbiological or histopathological tests. Six women had caseating tubercles in pelvis, of them two women had presence of mycobacterium on smear, one woman also had positive liquid culture. In two women endometrial smear was positive. None of the women had a positive GeneXpert test in peritoneal fluid. Conclusion: Genital TB is a clinical problem in infertile women. Even in women with confirmed genital TB the peritoneal fluid/washings were negative for mycobacterium. GeneXpert did not pick Mycobacterium in peritoneal fluid in women with genital TB. Hence, it is not a sensitive and good tool for the diagnosis of female genital TB.
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Affiliation(s)
- Smriti Agrawal
- Departments of Obstetrics and Gynaecology, KGMU, Lucknow, Uttar Pradesh, India
| | - Surya Kant
- Department of Respiratory Medicine, KGMU, Lucknow, Uttar Pradesh, India
| | - Vinita Das
- Departments of Obstetrics and Gynaecology, KGMU, Lucknow, Uttar Pradesh, India
| | - Amita Jain
- Department of Microbiology, KGMU, Lucknow, Uttar Pradesh, India
| | - Shambhavi Mishra
- Department of Statistics, Lucknow University, Lucknow, Uttar Pradesh, India
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Ashwini M, Ashwini N, Arunkumar N, Gunasheela D. A Study on Diagnostic Evaluation of Two Different Rapid DNA Polymerase Chain Reaction Techniques Namely Gene Xpert Mycobacterium Tuberculosis/Rifampin (MTB/RIF) and Mycoreal Polymerase Chain Reaction in the Diagnosis of Endometrial Tuberculosis Considering Culture as Gold Standard. J Hum Reprod Sci 2021; 13:290-295. [PMID: 33627978 PMCID: PMC7879844 DOI: 10.4103/jhrs.jhrs_16_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 06/04/2020] [Accepted: 10/03/2020] [Indexed: 12/04/2022] Open
Abstract
Context: The study involves the evaluation of two polymerase chain reaction (PCR) techniques one of which has been endorsed by the WHO for their diagnostic capabilities. Aims: The aim of this study is to evaluate the diagnostic accuracy of GeneXpert mycobacterium tuberculosis/Rifampin (MTB/RIF) and mycoreal PCR techniques in the diagnosis of endometrial tuberculosis (TB) considering culture as the gold standard. Settings and Design: A retrospective study conducted at Gunasheela surgical and maternity hospital. Patients who attended the outpatient department between January 2013 and August 2016, satisfying the eligibility criteria, were included in the study. Methodology: Women included in the study underwent endometrial pipelle sampling premenstrually after ruling out pregnancy in that cycle. Endometrial samples were tested for TB by Mycoreal PCR, Gene Xpert and BACTEC culture. Statistical Analysis Used: Statistical analysis was done using the R software version 3.6.1. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of test were calculated. Results: A total of 3229 samples were analyzed, of which 1754 were evaluated by Mycoreal TB PCR and 1475 were evaluated by Gene Xpert MTB/RIF assay. The sensitivity of mycoreal TB PCR technique was 34.78%, specificity was 99.08%, PPV was 33.33%, NPV was 99.13%, and accuracy was 98.23%. The sensitivity of GeneXpert MTB/RIF technique was 6.90%, specificity was 99.79%, PPV was 40.00%, NPV was 98.16%, and accuracy was 97.97%. Conclusions: MYCOREAL seemed to be more sensitive than Gene Xpert (MTB/RIF) considering culture as the gold standard in the diagnosis of endometrial TB.
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Affiliation(s)
- M Ashwini
- Department of Reproductive Medicine, Gunasheela Surgical and Maternity Hospital, Bengaluru, Karnataka, India
| | - N Ashwini
- Department of Reproductive Medicine, Gunasheela Surgical and Maternity Hospital, Bengaluru, Karnataka, India
| | - N Arunkumar
- Department of Reproductive Medicine, Gunasheela Surgical and Maternity Hospital, Bengaluru, Karnataka, India
| | - Devika Gunasheela
- Department of Reproductive Medicine, Gunasheela Surgical and Maternity Hospital, Bengaluru, Karnataka, India
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12
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Tiwari K, Prasad S, Tanwar R. Role of Gene Xpert in the Detection of Genital Tuberculosis in Endometrial Tissue among Women with Infertility. J Hum Reprod Sci 2021; 13:285-289. [PMID: 33627977 PMCID: PMC7879840 DOI: 10.4103/jhrs.jhrs_52_20] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Revised: 07/03/2020] [Accepted: 10/02/2020] [Indexed: 11/04/2022] Open
Abstract
Objective: The objective of the study is to evaluate the clinical utility of Gene Xpert compared with other available diagnostic modalities in prompt diagnosis of female genital tuberculosis (TB) causing infertility. Material and Methods: This was a prospective, cross-sectional analytical study. Premenstrual endometrial biopsy specimens were collected from 176 infertile women of reproductive age group suspected of having genital TB. Samples were processed for acid-fast bacilli, culture, histopathology, polymerase chain reaction (PCR), and Gene Xpert. Patients detected positive on Gene Xpert and PCR were subjected to laparoscopy to look for affirmative findings of genital TB. The results were analyzed using composite gold standard consisting of patients positive with culture, histopathology, and laparoscopy. Results: A total of 18 patients were found positive using composite gold standard. Laparoscopy was positive in 15 patients, whereas culture and histopathology were positive in three and two patients, respectively. Gene Xpert was positive in two patients. None of them was detected with rifampicin resistance. The sensitivity of Gene Xpert was 11.11% whereas the specificity was 100%. Conclusion: Since genital TB is a paucibacillary disease, multiple diagnostic modalities are needed for diagnosis. Gene Xpert appears to be a useful modality in diagnosis of genital TB, owing to its high specificity, and can be recommended in conditions where microscopy, culture, and histopathology are negative; however, further randomized studies are required to support our hypothesis.
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Affiliation(s)
- Kriti Tiwari
- Department of Obstetrics and Gynaecology, Maulana Azad Medical College and Lok Nayak Hospital, New Delhi, India
| | - Sudha Prasad
- Matritava Advanced IVF and Training Centre, New Delhi, India
| | - Renu Tanwar
- Department of Obstetrics and Gynaecology, Maulana Azad Medical College and Lok Nayak Hospital, New Delhi, India
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13
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Kohli M, Schiller I, Dendukuri N, Yao M, Dheda K, Denkinger CM, Schumacher SG, Steingart KR. Xpert MTB/RIF Ultra and Xpert MTB/RIF assays for extrapulmonary tuberculosis and rifampicin resistance in adults. Cochrane Database Syst Rev 2021; 1:CD012768. [PMID: 33448348 PMCID: PMC8078545 DOI: 10.1002/14651858.cd012768.pub3] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Xpert MTB/RIF Ultra (Xpert Ultra) and Xpert MTB/RIF are World Health Organization (WHO)-recommended rapid nucleic acid amplification tests (NAATs) widely used for simultaneous detection of Mycobacterium tuberculosis complex and rifampicin resistance in sputum. To extend our previous review on extrapulmonary tuberculosis (Kohli 2018), we performed this update to inform updated WHO policy (WHO Consolidated Guidelines (Module 3) 2020). OBJECTIVES To estimate diagnostic accuracy of Xpert Ultra and Xpert MTB/RIF for extrapulmonary tuberculosis and rifampicin resistance in adults with presumptive extrapulmonary tuberculosis. SEARCH METHODS Cochrane Infectious Diseases Group Specialized Register, MEDLINE, Embase, Science Citation Index, Web of Science, Latin American Caribbean Health Sciences Literature, Scopus, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform, the International Standard Randomized Controlled Trial Number Registry, and ProQuest, 2 August 2019 and 28 January 2020 (Xpert Ultra studies), without language restriction. SELECTION CRITERIA Cross-sectional and cohort studies using non-respiratory specimens. Forms of extrapulmonary tuberculosis: tuberculous meningitis and pleural, lymph node, bone or joint, genitourinary, peritoneal, pericardial, disseminated tuberculosis. Reference standards were culture and a study-defined composite reference standard (tuberculosis detection); phenotypic drug susceptibility testing and line probe assays (rifampicin resistance detection). DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed risk of bias and applicability using QUADAS-2. For tuberculosis detection, we performed separate analyses by specimen type and reference standard using the bivariate model to estimate pooled sensitivity and specificity with 95% credible intervals (CrIs). We applied a latent class meta-analysis model to three forms of extrapulmonary tuberculosis. We assessed certainty of evidence using GRADE. MAIN RESULTS 69 studies: 67 evaluated Xpert MTB/RIF and 11 evaluated Xpert Ultra, of which nine evaluated both tests. Most studies were conducted in China, India, South Africa, and Uganda. Overall, risk of bias was low for patient selection, index test, and flow and timing domains, and low (49%) or unclear (43%) for the reference standard domain. Applicability for the patient selection domain was unclear for most studies because we were unsure of the clinical settings. Cerebrospinal fluid Xpert Ultra (6 studies) Xpert Ultra pooled sensitivity and specificity (95% CrI) against culture were 89.4% (79.1 to 95.6) (89 participants; low-certainty evidence) and 91.2% (83.2 to 95.7) (386 participants; moderate-certainty evidence). Of 1000 people where 100 have tuberculous meningitis, 168 would be Xpert Ultra-positive: of these, 79 (47%) would not have tuberculosis (false-positives) and 832 would be Xpert Ultra-negative: of these, 11 (1%) would have tuberculosis (false-negatives). Xpert MTB/RIF (30 studies) Xpert MTB/RIF pooled sensitivity and specificity against culture were 71.1% (62.8 to 79.1) (571 participants; moderate-certainty evidence) and 96.9% (95.4 to 98.0) (2824 participants; high-certainty evidence). Of 1000 people where 100 have tuberculous meningitis, 99 would be Xpert MTB/RIF-positive: of these, 28 (28%) would not have tuberculosis; and 901 would be Xpert MTB/RIF-negative: of these, 29 (3%) would have tuberculosis. Pleural fluid Xpert Ultra (4 studies) Xpert Ultra pooled sensitivity and specificity against culture were 75.0% (58.0 to 86.4) (158 participants; very low-certainty evidence) and 87.0% (63.1 to 97.9) (240 participants; very low-certainty evidence). Of 1000 people where 100 have pleural tuberculosis, 192 would be Xpert Ultra-positive: of these, 117 (61%) would not have tuberculosis; and 808 would be Xpert Ultra-negative: of these, 25 (3%) would have tuberculosis. Xpert MTB/RIF (25 studies) Xpert MTB/RIF pooled sensitivity and specificity against culture were 49.5% (39.8 to 59.9) (644 participants; low-certainty evidence) and 98.9% (97.6 to 99.7) (2421 participants; high-certainty evidence). Of 1000 people where 100 have pleural tuberculosis, 60 would be Xpert MTB/RIF-positive: of these, 10 (17%) would not have tuberculosis; and 940 would be Xpert MTB/RIF-negative: of these, 50 (5%) would have tuberculosis. Lymph node aspirate Xpert Ultra (1 study) Xpert Ultra sensitivity and specificity (95% confidence interval) against composite reference standard were 70% (51 to 85) (30 participants; very low-certainty evidence) and 100% (92 to 100) (43 participants; low-certainty evidence). Of 1000 people where 100 have lymph node tuberculosis, 70 would be Xpert Ultra-positive and 0 (0%) would not have tuberculosis; 930 would be Xpert Ultra-negative and 30 (3%) would have tuberculosis. Xpert MTB/RIF (4 studies) Xpert MTB/RIF pooled sensitivity and specificity against composite reference standard were 81.6% (61.9 to 93.3) (377 participants; low-certainty evidence) and 96.4% (91.3 to 98.6) (302 participants; low-certainty evidence). Of 1000 people where 100 have lymph node tuberculosis, 118 would be Xpert MTB/RIF-positive and 37 (31%) would not have tuberculosis; 882 would be Xpert MTB/RIF-negative and 19 (2%) would have tuberculosis. In lymph node aspirate, Xpert MTB/RIF pooled specificity against culture was 86.2% (78.0 to 92.3), lower than that against a composite reference standard. Using the latent class model, Xpert MTB/RIF pooled specificity was 99.5% (99.1 to 99.7), similar to that observed with a composite reference standard. Rifampicin resistance Xpert Ultra (4 studies) Xpert Ultra pooled sensitivity and specificity were 100.0% (95.1 to 100.0), (24 participants; low-certainty evidence) and 100.0% (99.0 to 100.0) (105 participants; moderate-certainty evidence). Of 1000 people where 100 have rifampicin resistance, 100 would be Xpert Ultra-positive (resistant): of these, zero (0%) would not have rifampicin resistance; and 900 would be Xpert Ultra-negative (susceptible): of these, zero (0%) would have rifampicin resistance. Xpert MTB/RIF (19 studies) Xpert MTB/RIF pooled sensitivity and specificity were 96.5% (91.9 to 98.8) (148 participants; high-certainty evidence) and 99.1% (98.0 to 99.7) (822 participants; high-certainty evidence). Of 1000 people where 100 have rifampicin resistance, 105 would be Xpert MTB/RIF-positive (resistant): of these, 8 (8%) would not have rifampicin resistance; and 895 would be Xpert MTB/RIF-negative (susceptible): of these, 3 (0.3%) would have rifampicin resistance. AUTHORS' CONCLUSIONS Xpert Ultra and Xpert MTB/RIF may be helpful in diagnosing extrapulmonary tuberculosis. Sensitivity varies across different extrapulmonary specimens: while for most specimens specificity is high, the tests rarely yield a positive result for people without tuberculosis. For tuberculous meningitis, Xpert Ultra had higher sensitivity and lower specificity than Xpert MTB/RIF against culture. Xpert Ultra and Xpert MTB/RIF had similar sensitivity and specificity for rifampicin resistance. Future research should acknowledge the concern associated with culture as a reference standard in paucibacillary specimens and consider ways to address this limitation.
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MESH Headings
- Adult
- Antibiotics, Antitubercular/therapeutic use
- Bias
- Drug Resistance, Bacterial
- False Negative Reactions
- False Positive Reactions
- Humans
- Mycobacterium tuberculosis/drug effects
- Mycobacterium tuberculosis/isolation & purification
- Nucleic Acid Amplification Techniques/methods
- Nucleic Acid Amplification Techniques/statistics & numerical data
- Reagent Kits, Diagnostic
- Rifampin/therapeutic use
- Sensitivity and Specificity
- Tuberculosis/cerebrospinal fluid
- Tuberculosis/diagnosis
- Tuberculosis/drug therapy
- Tuberculosis, Lymph Node/cerebrospinal fluid
- Tuberculosis, Lymph Node/diagnosis
- Tuberculosis, Lymph Node/drug therapy
- Tuberculosis, Meningeal/cerebrospinal fluid
- Tuberculosis, Meningeal/diagnosis
- Tuberculosis, Meningeal/drug therapy
- Tuberculosis, Multidrug-Resistant/cerebrospinal fluid
- Tuberculosis, Multidrug-Resistant/diagnosis
- Tuberculosis, Multidrug-Resistant/drug therapy
- Tuberculosis, Pleural/cerebrospinal fluid
- Tuberculosis, Pleural/diagnosis
- Tuberculosis, Pleural/drug therapy
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Affiliation(s)
- Mikashmi Kohli
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada
| | - Ian Schiller
- Centre for Outcomes Research, McGill University Health Centre - Research Institute, Montreal, Canada
| | - Nandini Dendukuri
- Centre for Outcomes Research, McGill University Health Centre - Research Institute, Montreal, Canada
| | - Mandy Yao
- Centre for Outcomes Research, McGill University Health Centre - Research Institute, Montreal, Canada
| | - Keertan Dheda
- Centre for Lung Infection and Immunity Unit, Department of Medicine and UCT Lung Institute, University of Cape Town, Cape Town, South Africa
- Faculty of Infectious and Tropical Diseases, Department of Immunology and Infection, London School of Hygiene and Tropical Medicine, London, UK
| | - Claudia M Denkinger
- FIND, Geneva , Switzerland
- Division of Tropical Medicine, Centre for Infectious Diseases, University Hospital Heidelberg, Heidelberg, Germany
| | | | - Karen R Steingart
- Honorary Research Fellow, Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
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14
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Sharma's abdominal compartmentalization sign: A new laparoscopic sign for abdomino-pelvic tuberculosis. Indian J Tuberc 2020; 67:578-585. [PMID: 33077063 DOI: 10.1016/j.ijtb.2020.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 06/25/2020] [Indexed: 11/22/2022]
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15
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Sharma JB, Sharma E, Sharma S, Singh J, Chopra N. Genital tb-diagnostic algorithm and treatment. Indian J Tuberc 2020; 67:S111-S118. [PMID: 33308655 DOI: 10.1016/j.ijtb.2020.10.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 10/09/2020] [Indexed: 10/23/2022]
Abstract
Female genital tuberculosis (FGTB) is a common cause of infertility in India but its diagnosis remains elusive due to paucibacillary nature of disease. Traditional methods of diagnosis include demonstration of acid fast bacilli on endometrial or peritoneal biopsy or epithelioid granuloma on the biopsy or positive gene Xpert on the biopsy, but they are positive in small percentage of cases only missing diagnosis in many cases. Positive polymerase chain reaction (PCR) alone is not taken for diagnosis due to high false positivity. Diagnostic laparoscopy and hysteroscopy can detect many cases by direct demonstration of TB lesions. Composite reference standard is a useful method to diagnose FGTB. This review discusses various diagnostic modalities including endometrial or peritoneal biopsy to detect acid fast bacilli on microscopic or culture or epithelioid granuloma, role of PCR, role of radiological imaging (hysterosalpingography, ultrasound, CT scan, MRI and PET-CT scan) and role of endoscopic techniques (laparoscopy and hysteroscopy) in diagnosis of FGTB including role of composite reference standard. The International and National studies highlight the role of composite reference standard and its components like demonstration of AFB on microscopy or culture of endometrial or peritoneal biopsy or epithelioid granuloma or gene Xpert or PCR or latest tests like loop-mediated isothermal amplification (TB-LAMP) test and other newer molecular methods like Xpert Ultra for diagnosis of FGTB. It also detects role of endoscopy in FGTB and role of diagnostic algorithm for diagnosis of FGTB. Treatment is with four primary drugs (rifampicin, isoniazid, ethambutol and pyrazinamide) for two months followed by three drugs (rifampicin, isoniazid and ethambutol) daily orally for 4 months for drug sensitive FGTB. Shorter Multidrug-resistant TB (MDR-TB) regimen is given for Rifampicin resistant (RR)/MDR confined to only FGTB while longer all oral regimen is given for RR/MDR with or without additional drug resistance, HIV seropositives with FGTB or involvement of other sites or pulmonary TB (PTB) along with FGTB. Composite reference standard which combines various diagnostic modalities is a useful strategy to diagnose FGTB.
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Affiliation(s)
- Jai Bhagwan Sharma
- Professor, Department of Obstetrics & Gynecology, All India Institute of Medical Sciences, New Delhi, India.
| | - Eshani Sharma
- Senior Research Fellow, Department of Obstetrics & Gynecology, All India Institute of Medical Sciences, New Delhi, India
| | - Sangeeta Sharma
- Professor and Head, Department of Paediatrics, National Institute of Tuberculosis& Respiratory Diseases, New Delhi, India
| | - Janmeeta Singh
- Research Officer, Department of Obstetrics & Gynecology, All India Institute of Medical Sciences, New Delhi, India
| | - Namita Chopra
- Medical Officer, Department of Obstetrics & Gynecology, Atal Bihari Vajpayee Institute of Medical Sciences, New Delhi, India
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16
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Sharma JB, Dharmendra S, Jain S, Sharma SK, Singh UB, Soneja M, Sinha S, Vanamail P. Evaluation of Gene Xpert as compared to conventional methods in diagnosis of Female Genital Tuberculosis. Eur J Obstet Gynecol Reprod Biol 2020; 255:247-252. [PMID: 33256922 DOI: 10.1016/j.ejogrb.2020.09.046] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 09/23/2020] [Accepted: 09/28/2020] [Indexed: 12/01/2022]
Abstract
To evaluate Gene Xpert for diagnosis of Female Genital Tuberculosis (FGTB) as compared to conventional methods. STUDY DESIGN It was a prospective study conducted over 167 cases of infertile female genital tuberculosis (FGTB) diagnosed on composite reference standard (CRS) (smear for AFB, histopathological evidence of epithelioid granuloma or definite or possible findings of tuberculosis on laparoscopy). All women underwent endometrial biopsy for AFB microscopy, culture, gene Xpert, PCR and histopathology) and laparoscopy and hysteroscopy for diagnosis and prognostication of disease. The results of Gene Xpert were compared with conventional methods in detection of FGTB. All patients were treated with 6 months course of rifampicin (R), isoniazid (H), pyrazinamide (Z) and ethambutol (E) (RHZE for 2 months, RHE for 4 months) using directly observed treatment short course strategy. RESULTS Mean age, parity, body mass index and history of contact was 28.3 years, 0.28, 22.9 Kg/m2 and 38.92% respectively. Primary infertility was seen in 87.42% cases with mean duration of 2.42 years. Menstrual dysfunctions, abdominal or pelvic pain and lump were seen in 38.92%, 14.37% and 10.77% cases. Abnormal vaginal discharge and adnexal mass were seen in 28.14% and 13.17 % cases. On diagnostic laparoscopy, definite findings of tuberculosis (beaded tubes, tuebrcles and caseous nodules) were seen in 96 (57.48%) women while probable findings of tuberculosis (pelvic or abdominal adhesions, hydrosaplinx, tubo-ovarian mass, pyosalpinx) were seen in 81 (48.50%) women. On laboratory investigations, positive AFB on microscopy or culture was seen in 2.99% casess, PCR was positive in 47.90% gene Xpert was positive in 18.56% cases while epitheloid granuloma was seen on histopathology in 16 (9.58%) cases. Gene Xpert had sensitivity of 35.63%, specificity of 100%, positive predictive value of 100% and negative predictive value of 58.82% and diagnostic accuracy of 66.47% in the present study. CONCLUSION Gene Xpert is a very useful test to rule in tuberculosis whereas when it is negative it is not a good test to rule out tuberculosis.
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Affiliation(s)
- Jai B Sharma
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi, India.
| | - Sona Dharmendra
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi, India
| | - Shefali Jain
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi, India
| | - S K Sharma
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Urvashi B Singh
- Department of Microbiology, All India Institute of Medical Sciences, New Delhi, India
| | - Manish Soneja
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Sanjeev Sinha
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - P Vanamail
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi, India
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17
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K Mehta P, Kamra E. Recent trends in diagnosis of urogenital tuberculosis. Future Microbiol 2020; 15:159-162. [DOI: 10.2217/fmb-2019-0323] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Promod K Mehta
- Centre for Biotechnology, Maharshi Dayanand University, Rohtak 124001, India
| | - Ekta Kamra
- Centre for Biotechnology, Maharshi Dayanand University, Rohtak 124001, India
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18
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Munne KR, Tandon D, Chauhan SL, Patil AD. Female genital tuberculosis in light of newer laboratory tests: A narrative review. Indian J Tuberc 2020; 67:112-120. [PMID: 32192604 DOI: 10.1016/j.ijtb.2020.01.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 10/10/2019] [Accepted: 01/03/2020] [Indexed: 10/25/2022]
Abstract
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.
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Affiliation(s)
- K R Munne
- Department of Clinical Research, ICMR-National Institute for Research in Reproductive Health (NIRRH), JM Street, Parel, 400012, Mumbai, India
| | - D Tandon
- Department of Clinical Research, ICMR-National Institute for Research in Reproductive Health (NIRRH), JM Street, Parel, 400012, Mumbai, India
| | - S L Chauhan
- Department of Clinical and Operational Research, ICMR-National Institute for Research in Reproductive Health (NIRRH), JM Street, Parel, 400012, Mumbai, India
| | - A D Patil
- Department of Clinical Research, ICMR-National Institute for Research in Reproductive Health (NIRRH), JM Street, Parel, 400012, Mumbai, India.
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19
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Abstract
Female genital tuberculosis (FGTB) is caused by Mycobacterium tuberculosis (rarely Mycobacterium bovis and/or atypical mycobacteria) being usually secondary to TB of the lungs or other organs with infection reaching through haematogenous, lymphatic route or direct spread from abdominal TB. In FGTB, fallopian tubes are affected in 90 per cent women, whereas uterine endometrium is affected in 70 per cent and ovaries in about 25 per cent women. It causes menstrual dysfunction and infertility through the damage of genital organs. Some cases may be asymptomatic. Diagnosis is often made from proper history taking, meticulous clinical examination and judicious use of investigations, especially endometrial aspirate (or biopsy) and endoscopy. Treatment is through multi-drug antitubercular treatment for adequate time period (rifampicin, isoniazid, pyrazinamide, ethambutol daily for 60 days followed by rifampicin, isoniazid, ethambutol daily for 120 days). Treatment is given for 18-24 months using the second-line drugs for drug-resistant (DR) cases. With the advent of increased access to rapid diagnostics and newer drugs, the management protocol is moving towards achieving universal drug sensitivity testing and treatment with injection-free regimens containing newer drugs, especially for new and previously treated DR cases.
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Affiliation(s)
- Jai Bhagwan Sharma
- Department of Obstetrics & Gynaecology, All India Institute of Medical Sciences, New Delhi, India
| | - Eshani Sharma
- Department of Obstetrics & Gynaecology, All India Institute of Medical Sciences, New Delhi, India
| | - Sangeeta Sharma
- Department of Paediatrics, National Institute of TB & Respiratory Diseases, New Delhi, India
| | - Sona Dharmendra
- Department of Obstetrics & Gynaecology, All India Institute of Medical Sciences, New Delhi, India
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20
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Sharma JB. Sharma's sigmoid colonic adhesive band - A new laparoscopic sign in female genital tuberculosis. Indian J Tuberc 2019; 67:327-332. [PMID: 32825859 DOI: 10.1016/j.ijtb.2019.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 06/14/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Female genital tuberculosis (FGTB) is a form of extra pulmonary tuberculosis (EPTB) affecting women of reproductive age group. It causes significant morbidity in women especially infertility particularly in developing countries. Diagnosis is by endometrial sampling for acid fast bacilli (AFB) microscopy, culture, gene Xpert, polymerase chain reaction (PCR), histopathological evidence of epithelioid granuloma and by laparoscopic findings suggestive of tuberculosis. AIM Present study was conducted to observe the prevalence of a new "Sharma's Sigmoid colonic adhesive band "in FGTB on laparoscopy. METHODS It was a prospective study in a tertiary referral center as a part of our ongoing tuberculosis project on 148 infertile women found to have FGTB on microbiological or laparoscopic findings over previous 10 years. A new laparoscopic "Sharma's Sigmoid colonic adhesive band" was looked for in these cases on laparoscopy. RESULTS The mean age, parity and duration of infertility and incidence of poor socioeconomic status was 26.9 years, 0.49, 5.3 years and 65.54% respectively. All patients had infertility with 83.78% primary and 16.22% secondary infertility while menstrual dysfuction especially hypomenorrhoea (31.75%), oligomenorrhoea (32.48%) were seen in respective cases. Constitutional symptoms like pyrexia (21.62%), weight loss (31.75%) appetite loss (33.5%) and abdominal pain (11.48%) and pelvic pain (27.70%) or abdominal mass (8.78%) and pelvic masses (35.81%) were also seen. Diagnosis of FGTB was made on endometrial or peritoneal biopsy microscopy or culture for AFB or positive gene Xpert or positive polymerase chain reaction (PCR) or histopathological demonstration of epithelioid granuloma or on laparoscopic findings of FGTB. Various laparoscopic findings were tubercles on pelvic organs (45.27%), shaggy areas (white deposits) on pelvic organs (43.91%),beaded or convoluted tubes (9.45%), hyperemic tubes (29.05%), caseous nodules in pelvis (29.72%), encysted ascites (14.18%), abdominal adhesions (32.43%), pelvic adhesions (42.56%), calcified and rigid tubes (6.08%). The new laparoscopic sigmoid colonic adhesive band was seen in 49 (33.10%) patients of FGTB. CONCLUSION The new laparoscopic "Sharma's Sigmoid colonic adhesive band" appears to be an important finding in patients with FGTB.
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Affiliation(s)
- Jai Bhagwan Sharma
- Department of Obstetrics and Gynaecology, All India Institute of Medical Science, New Delhi, 110029, India.
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21
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Kohli M, Schiller I, Dendukuri N, Dheda K, Denkinger CM, Schumacher SG, Steingart KR. Xpert ® MTB/RIF assay for extrapulmonary tuberculosis and rifampicin resistance. Cochrane Database Syst Rev 2018; 8:CD012768. [PMID: 30148542 PMCID: PMC6513199 DOI: 10.1002/14651858.cd012768.pub2] [Citation(s) in RCA: 115] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Tuberculosis (TB) is the world's leading infectious cause of death. Extrapulmonary TB accounts for 15% of TB cases, but the proportion is increasing, and over half a million people were newly diagnosed with rifampicin-resistant TB in 2016. Xpert® MTB/RIF (Xpert) is a World Health Organization (WHO)-recommended, rapid, automated, nucleic acid amplification assay that is used widely for simultaneous detection of Mycobacterium tuberculosis complex and rifampicin resistance in sputum specimens. This Cochrane Review assessed the accuracy of Xpert in extrapulmonary specimens. OBJECTIVES To determine the diagnostic accuracy of Xpert a) for extrapulmonary TB by site of disease in people presumed to have extrapulmonary TB; and b) for rifampicin resistance in people presumed to have extrapulmonary TB. SEARCH METHODS We searched the Cochrane Infectious Diseases Group Specialized Register, MEDLINE, Embase, Science Citation Index, Web of Science, Latin American Caribbean Health Sciences Literature (LILACS), Scopus, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform, the International Standard Randomized Controlled Trial Number (ISRCTN) Registry, and ProQuest up to 7 August 2017 without language restriction. SELECTION CRITERIA We included diagnostic accuracy studies of Xpert in people presumed to have extrapulmonary TB. We included TB meningitis and pleural, lymph node, bone or joint, genitourinary, peritoneal, pericardial, and disseminated TB. We used culture as the reference standard. For pleural TB, we also included a composite reference standard, which defined a positive result as the presence of granulomatous inflammation or a positive culture result. For rifampicin resistance, we used culture-based drug susceptibility testing or MTBDRplus as the reference standard. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data, assessed risk of bias and applicability using the QUADAS-2 tool. We determined pooled predicted sensitivity and specificity for TB, grouped by type of extrapulmonary specimen, and for rifampicin resistance. For TB detection, we used a bivariate random-effects model. Recognizing that use of culture may lead to misclassification of cases of extrapulmonary TB as 'not TB' owing to the paucibacillary nature of the disease, we adjusted accuracy estimates by applying a latent class meta-analysis model. For rifampicin resistance detection, we performed univariate meta-analyses for sensitivity and specificity separately to include studies in which no rifampicin resistance was detected. We used theoretical populations with an assumed prevalence to provide illustrative numbers of patients with false positive and false negative results. MAIN RESULTS We included 66 unique studies that evaluated 16,213 specimens for detection of extrapulmonary TB and rifampicin resistance. We identified only one study that evaluated the newest test version, Xpert MTB/RIF Ultra (Ultra), for TB meningitis. Fifty studies (76%) took place in low- or middle-income countries. Risk of bias was low for patient selection, index test, and flow and timing domains and was high or unclear for the reference standard domain (most of these studies decontaminated sterile specimens before culture inoculation). Regarding applicability, in the patient selection domain, we scored high or unclear concern for most studies because either patients were evaluated exclusively as inpatients at tertiary care centres, or we were not sure about the clinical settings.Pooled Xpert sensitivity (defined by culture) varied across different types of specimens (31% in pleural tissue to 97% in bone or joint fluid); Xpert sensitivity was > 80% in urine and bone or joint fluid and tissue. Pooled Xpert specificity (defined by culture) varied less than sensitivity (82% in bone or joint tissue to 99% in pleural fluid and urine). Xpert specificity was ≥ 98% in cerebrospinal fluid, pleural fluid, urine, and peritoneal fluid.Xpert testing in cerebrospinal fluidXpert pooled sensitivity and specificity (95% credible interval (CrI)) against culture were 71.1% (60.9% to 80.4%) and 98.0% (97.0% to 98.8%), respectively (29 studies, 3774 specimens; moderate-certainty evidence).For a population of 1000 people where 100 have TB meningitis on culture, 89 would be Xpert-positive: of these, 18 (20%) would not have TB (false-positives); and 911 would be Xpert-negative: of these, 29 (3%) would have TB (false-negatives).For TB meningitis, ultra sensitivity and specificity against culture (95% confidence interval (CI)) were 90% (55% to 100%) and 90% (83% to 95%), respectively (one study, 129 participants).Xpert testing in pleural fluidXpert pooled sensitivity and specificity (95% CrI) against culture were 50.9% (39.7% to 62.8%) and 99.2% (98.2% to 99.7%), respectively (27 studies, 4006 specimens; low-certainty evidence).For a population of 1000 people where 150 have pleural TB on culture, 83 would be Xpert-positive: of these, seven (8%) would not have TB (false-positives); and 917 would be Xpert-negative: of these, 74 (8%) would have TB (false-negatives).Xpert testing in urineXpert pooled sensitivity and specificity (95% CrI) against culture were 82.7% (69.6% to 91.1%) and 98.7% (94.8% to 99.7%), respectively (13 studies, 1199 specimens; moderate-certainty evidence).For a population of 1000 people where 70 have genitourinary TB on culture, 70 would be Xpert-positive: of these, 12 (17%) would not have TB (false-positives); and 930 would be Xpert-negative: of these, 12 (1%) would have TB (false-negatives).Xpert testing for rifampicin resistanceXpert pooled sensitivity (20 studies, 148 specimens) and specificity (39 studies, 1088 specimens) were 95.0% (89.7% to 97.9%) and 98.7% (97.8% to 99.4%), respectively (high-certainty evidence).For a population of 1000 people where 120 have rifampicin-resistant TB, 125 would be positive for rifampicin-resistant TB: of these, 11 (9%) would not have rifampicin resistance (false-positives); and 875 would be negative for rifampicin-resistant TB: of these, 6 (1%) would have rifampicin resistance (false-negatives).For lymph node TB, the accuracy of culture, the reference standard used, presented a greater concern for bias than in other forms of extrapulmonary TB. AUTHORS' CONCLUSIONS In people presumed to have extrapulmonary TB, Xpert may be helpful in confirming the diagnosis. Xpert sensitivity varies across different extrapulmonary specimens, while for most specimens, specificity is high, the test rarely yielding a positive result for people without TB (defined by culture). Xpert is accurate for detection of rifampicin resistance. For people with presumed TB meningitis, treatment should be based on clinical judgement, and not withheld solely on an Xpert result, as is common practice when culture results are negative.
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Affiliation(s)
- Mikashmi Kohli
- McGill UniversityDepartment of Epidemiology, Biostatistics and Occupational HealthMontrealCanada
| | - Ian Schiller
- McGill University Health Centre ‐ Research InstituteDivision of Clinical EpidemiologyMontrealCanada
| | - Nandini Dendukuri
- McGill University Health Centre ‐ Research InstituteDivision of Clinical EpidemiologyMontrealCanada
| | - Keertan Dheda
- University of Cape Town3 Centre for Lung Infection and Immunity Unit, Department of Medicine and UCT Lung InstituteCape TownSouth Africa
| | | | | | - Karen R Steingart
- Department of Clinical Sciences, Liverpool School of Tropical MedicineHonorary Research FellowPembroke PlaceLiverpoolUK
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Sharma JB, Goyal M, Kumar S, Roy KK, Sharma E, Arora R. Concomitant female genital tuberculosis and endometriosis. Indian J Tuberc 2017; 64:173-177. [PMID: 28709484 DOI: 10.1016/j.ijtb.2017.01.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Accepted: 01/17/2017] [Indexed: 11/28/2022]
Abstract
AIMS To demonstrate an association between female genital tuberculosis (FGTB) and endometriosis. METHODS A total of 16 women who underwent laparoscopy (12 cases) or laparotomy (4 cases) and were found to have female genital tuberculosis and endometriosis were enrolled in this retrospective study. RESULTS The mean age and parity were 28.2 years and 0.2, respectively. Past history of tuberculosis was present in 75% of the women (pulmonary in 50%). Menstrual dysfunction (especially oligomenorrhoea and dysmenorrhoea), constitutional symptoms, infertility, abdominal pain and lump were the main complaints. Diagnosis of FGTB was made by positive acid-fast bacilli (AFB) on microscopy, culture of endometrial aspirate, positive polymerase chain reaction (PCR), histopathological finding of epitheliod granuloma or findings of TB on laparoscopy or laparotomy. Diagnosis of endometriosis was made by laparoscopy or laparotomy. Pelvic adhesions were seen in all women, whereas frozen pelvis was seen in 7 (43.7%) women. Surgery was performed, which was laparoscopic adhesiolysis in 12 (75%), drainage of endometrioma in 12 (75%), cystectomy in 8 (50%), and total abdominal hysterectomy with bilateral salpingo-oophorectomy in 4 (25%) cases. With more then one type of (surgery in many cases). DISCUSSION Female genital tuberculosis and endometriosis may have similar manifestations and can co-exist.
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Affiliation(s)
- Jai Bhagwan Sharma
- Professor, Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India.
| | - Manu Goyal
- Senior Resident, Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India
| | - Sunesh Kumar
- Professor, Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India
| | - Kallol Kumar Roy
- Professor, Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India
| | - Eshani Sharma
- Senior Research Fellow, Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India
| | - Raksha Arora
- Professor and Head, Department of Obstetrics and Gynecology, Santosh Medical College, Ghaziabad, Uttar Pradesh, India
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