Sharma's sigmoid colonic adhesive band - A new laparoscopic sign in female genital tuberculosis

JB Sharma's white cotton ball sign: A new laparoscopic sign in abdominopelvic tuberculosis

BACKGROUND

Abdominopelvic tuberculosis (TB) is a variant of extrapulmonary TB causing significant morbidity, including infertility.

MATERIALS AND METHODS

Results of 87 cases of diagnostic laparoscopy in cases of abdominopelvic TB diagnosed on composite reference standard (CRS) for demonstration of new laparoscopic white cotton ball sign are presented.

RESULTS

Mean age, parity and duration of infertility were 27.2 years, 0.21 and 3.1 years, respectively. Oligomenorrhoea and hypomenorrhea were seen in 35 (40.22%) and 32 (36.78%) cases, while infertility was seen in all 87 (100%) cases while abdominal mass was seen in 27 (31.03%) cases and pelvic mass in 37 (42.58%) cases. Positive acid fast bacilli on microscopy and culture of endometrial biopsy was seen in 3.34% and 6.89% cases while epithelioid granuloma was seen in 12.64% cases on endometrial biopsy and in 13.79% cases on peritoneal biopsy. Positive polymerase chain reaction was seen in all cases while definitive abdominal pelvic TB was seen in 35 (40.1%) cases and probable findings in 42 (48.27%) cases. A new laparoscopic white cotton ball sign (resembling a large white cotton ball) was observed in 5 (5.74%) cases and biopsy from 3 showed it to be epithelioid granulomas positive.

CONCLUSION

Demonstration of a new white cotton ball sign on laparoscopy seems to be a useful finding in abdominal pelvic TB.

Immune disturbances in female genital tuberculosis and latent genital tuberculosis

BACKGROUND

Female genital tuberculosis (FGTB), an important clinical sub-type of extra-pulmonary tuberculosis (EPTB) is responsible for about 10% cases of infertility in India. Both FGTB and latent genital tuberculosis (LGTB) can cause infertility through blockage of fallopian tubes and through altered uterine endometrial receptivity.

AIMS

This review tries to elucidates the role of various immune factors in FGTB and LGTB.

CONTENT

Various immune disturbances are observed in FGTB and LGTB like growth factors and cytokines which inhibit implantation and several inflammatory signaling pathways like mitogen activated protein kinase (MAPK), natural killer (NK) cells, nuclear factor kappa-B (NF-KB), tumor necrosis factor (TNF), and toll like receptors (TLR) signaling are dysregulated. These altered immune factors and pathways may be detected in the endometrial biopsies at the early stages of disease before permanent damage. Prompt and adequate treatment with the four anti-tubercular drugs (rifampicin [R], isoniazid [H], pyrazinamide [Z], and ethambutol [E]) can increase pregnancy rates in some of these women. Assisted reproduction especially in-vitro fertilization and embryo transfer may be required for some women.

IMPLICATIONS

Inflammatory pathways identified from the gene profiling have enabled development of potential biomarkers for early diagnosis of FGTB. Immunomodulation and novel biotechniques like stem cell transplantation, nanoparticles and host directed therapies are being tried in selected patients of FGTB and LGTB with promising results.

Recent Advances in Diagnosis and Management of Female Genital Tuberculosis

Female genital tuberculosis (FGTB) is an important cause of significant morbidity and infertility. Gold-standard diagnosis by demonstration of acid fast bacilli on microscopy or culture or detection of epithelioid granuloma on histopathology of endometrial or peritoneal biopsy is positive in only small percentage of cases due to its paucibacillary nature. Use of gene Xpert on endometrial or peritoneal biopsy has improved sensitivity of diagnosis. Composite reference standard (CRS) is a significant landmark in its diagnosis in which combination of factors like AFB on microscopy or culture, positive gene Xpert, epithelioid granuloma on endometrial or peritoneal biopsy, demonstration of definite or probable findings of FGTB on laparoscopy or hysteroscopy. There have been many advances and changes in management of FGTB recently. The program is now called National Tuberculosis Elimination Program (NTEP), and categorization of TB has been stopped. Now, patients are divided into drug-sensitive FGTB for which rifampicin (R), isoniazid (H), pyrazinamide (Z) and ethambutol (E) are given orally daily for 2 months followed by three drugs (rifampicin, isoniazid and ethambutol (RHE) orally daily for next 4 months. Multi-drug-resistant FGTB is treated with shorter MDR TB regimen of 9-11 months or longer MDR TB regimen of 18-20 months with reserved drugs. In vitro fertilization and embryo transfer have good results for blocked tubes and receptive endometrium, while surrogacy or adoption is advised for severe grades of Asherman's syndrome.