1
|
Sharma JB, Dharmendra S, Rapaka G, Singh UB, Kriplani A, Kumar S, Dash NR, Nayyer R. Comparative study on complications and difficulties in laparoscopy in female genital tuberculosis cases versus non-tuberculosis cases. J Minim Access Surg 2024; 20:207-215. [PMID: 37357491 PMCID: PMC11095795 DOI: 10.4103/jmas.jmas_3_23] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 03/13/2023] [Accepted: 03/24/2023] [Indexed: 06/27/2023] Open
Abstract
BACKGROUND AND OBJECTIVE Female genital tuberculosis (FGTB) is an important type of extrapulmonary tuberculosis (TB) associated with morbidity especially infertility in developing countries. Laparoscopy may be difficult and hazardous in FGTB. The aim of the study was to observe the difficulties and complications of laparoscopy in FGTB cases. MATERIALS AND METHODS It was a prospective study over 12 years' period on 412 cases of diagnostic laparoscopy performed on FGTB cases with infertility. All patients underwent history taking and clinical examination and endometrial sampling for acid-fast bacilli (AFB) microscopy, culture, polymerase chain reaction (PCR), gene Xpert (last 212 cases) and histopathological evidence of epithelioid granuloma. Another 412 cases of diagnostic laparoscopy in the absence of FGTB performed during same time were taken as controls from the pool of non-TB cases. Various difficulties and complications were noted in both groups and statistical analysis was done. RESULTS Mean age, parity, body mass index and duration of infertility were 26.8 versus 25.4 years, 0.32 versus 0.28, 23.15 versus 25.28 Kg/m 2 and 4.15 versus 5.12 years, respectively. Primary and secondary infertility was seen in 78.6% and 20.38% of cases in the study group and 74.75% and 25.24% in the control group, respectively. Endometrial biopsy showed AFB microscopy in 5.3%, culture in 6.3%, epithelioid granuloma in 15.77% and on peritoneal biopsy granuloma in 6.55%, positive PCR in 368 (89.32%) and positive gene Xpert in 38 out of 212 (17.92%, out of last 212 cases). Definite findings of FGTB were seen in 171 (41.50%) cases. Probable findings of FGTB were seen in 241 (58.49%) cases. Various complications were difficulty in the creation of pneumoperitoneum or insertion of trocar and cannula in 16.74% and 13.10% of cases as compared to 1.94% and 1.69% in the control group. Excessive bleeding was seen in 5.09% versus 0.97% cases, respectively. Various injuries observed were bowel injury in 1.69% versus 0.24% cases (small bowel in 1.21% vs. 0.24%, large bowel in 0.48% vs. 0.1%), while bladder injury was seen in 0.97% versus 0.24% cases, subacute intestinal obstruction was seen in 5.8% versus 0.72% cases respectively while flare up of TB was seen in 5.09% versus 0% in cases and controls, respectively. Wound infection was seen in 8.48% versus 1.25% cases, respectively. INTERPRETATION AND CONCLUSION FGTB is associated with increased complications and difficulties as compared to laparoscopy in other cases.
Collapse
Affiliation(s)
| | - Sona Dharmendra
- Department of Obstetrics and Gynaecology, AIIMS, New Delhi, India
| | - Gawri Rapaka
- Department of Obstetrics and Gynaecology, AIIMS, New Delhi, India
| | | | - Alka Kriplani
- Department of Obstetrics and Gynaecology, AIIMS, New Delhi, India
| | - Sunesh Kumar
- Department of Obstetrics and Gynaecology, AIIMS, New Delhi, India
| | - N. R. Dash
- Department of GI Surgery, AIIMS, New Delhi, India
| | | |
Collapse
|
2
|
Sharma JB. JB Sharma's white cotton ball sign: A new laparoscopic sign in abdominopelvic tuberculosis. J Minim Access Surg 2024; 20:24-29. [PMID: 36695245 PMCID: PMC10898634 DOI: 10.4103/jmas.jmas_227_22] [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: 08/08/2022] [Revised: 10/31/2022] [Accepted: 12/02/2022] [Indexed: 01/22/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Jai Bhagwan Sharma
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi, India
| |
Collapse
|
3
|
Sharma JB, Sharma S, Sharma E, Dharmendra S, Singh S. Immune disturbances in female genital tuberculosis and latent genital tuberculosis. Am J Reprod Immunol 2023; 89:e13632. [PMID: 36494901 DOI: 10.1111/aji.13632] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 09/07/2022] [Accepted: 10/03/2022] [Indexed: 12/14/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Jai Bhagwan Sharma
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi, India
| | - Sangeeta Sharma
- Department of Paediatrics, National Institute of Tuberculosis and Respiratory Diseases, New Delhi, India
| | - Eshani Sharma
- Department of Medicine, KU School of Medicine, Wichita, Kansas, USA
| | - Sona Dharmendra
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi, India
| | - Sheena Singh
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi, India
| |
Collapse
|
4
|
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.
Collapse
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
| |
Collapse
|
5
|
Sharma JB, Sharma E, Sharma S, Dharmendra S. Recent Advances in Diagnosis and Management of Female Genital Tuberculosis. J Obstet Gynaecol India 2021; 71:476-487. [PMID: 34483510 PMCID: PMC8402974 DOI: 10.1007/s13224-021-01523-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 06/28/2021] [Indexed: 12/19/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- J. B. Sharma
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, Room No. 3064A, IIIrd Floor, Teaching Block, New Delhi, 110029 India
| | - Eshani Sharma
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, Room No. 3064A, IIIrd Floor, Teaching Block, New Delhi, 110029 India
| | - Sangeeta Sharma
- Department of Paediatrics, National Institute of Tuberculosis and Respiratory Diseases, New Delhi, India
| | - Sona Dharmendra
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, Room No. 3064A, IIIrd Floor, Teaching Block, New Delhi, 110029 India
| |
Collapse
|
6
|
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]
|
7
|
Elzein F, Kharraz R, Boudal A, Mohamed H, Mursi M, Kuriry H, Albarrak A, AlSherbeeni N. Abdominal tuberculosis in a tertiary care centre in Saudi Arabia. Indian J Tuberc 2020; 68:236-241. [PMID: 33845958 DOI: 10.1016/j.ijtb.2020.09.007] [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: 07/22/2020] [Accepted: 09/04/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVES Abdominal tuberculosis (ATB) is the second most common type of extra-pulmonary tuberculosis. Though it does not usually pose a significant risk of infectivity, ATB can go unidentified and progress to disseminated infection. The aim of this study is to highlight the incidence and outcome of this infection in a tertiary care centre in the Kingdom of Saudi Arabia (KSA). METHODS In this retrospective study, we included all ATB patients admitted to our centre between January 1 st, 2010 and December 31, 2018. A total of 42 patients with a median age of 49 (range 18-83 years, 78.6% males) were identified. RESULTS The most common presentation was abdominal pain, weight loss, and abdominal distension. All the patients were HIV negative; however, 50% had a comorbid condition, mainly diabetes mellitus, chronic renal failure, and liver cirrhosis. Tuberculous peritonitis was the predominant type of ATB. Suspicious and potentially malignant abdominal masses appeared on the abdominal CT scans of six patients. This suggest that TB should be excluded in patients from endemic area presenting with abdominal masses. All patients received standard anti-tuberculous medication for an average duration of 7.4 months. The outcome was excellent with 88%% achieving complete response. Adjunctive corticosteroids were not used, and none of the patients had a surgical complication. CONCLUSION The diagnosis of ATB is challenging. It can mimic inflammatory bowel disease in young populations and malignancy in middle-aged and elderly population. For this reason, a high index of suspicion with prompt treatment is required to improve the prognosis and prevent complications.
Collapse
Affiliation(s)
- Fatehi Elzein
- Infectious Diseases Unit, Prince Sultan Military Medical City (PSMMC), Riyadh, Saudi Arabia.
| | - Razan Kharraz
- Infectious Diseases Unit, Prince Sultan Military Medical City (PSMMC), Riyadh, Saudi Arabia
| | - Ayah Boudal
- Infectious Diseases Unit, Prince Sultan Military Medical City (PSMMC), Riyadh, Saudi Arabia
| | - Haris Mohamed
- Infectious Diseases Unit, Prince Sultan Military Medical City (PSMMC), Riyadh, Saudi Arabia
| | - Mohammed Mursi
- Infectious Diseases Unit, Prince Sultan Military Medical City (PSMMC), Riyadh, Saudi Arabia
| | - Hadi Kuriry
- Hepatology Unit, Sultan Military Medical City (PSMMC), Riyadh, Saudi Arabia
| | - Ali Albarrak
- Infectious Diseases Unit, Prince Sultan Military Medical City (PSMMC), Riyadh, Saudi Arabia
| | - Nisreen AlSherbeeni
- Infectious Diseases Unit, Prince Sultan Military Medical City (PSMMC), Riyadh, Saudi Arabia
| |
Collapse
|