genital tuberculosis- newer trends in the diagnostic modalities
TRANSCRIPT
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Gential Tuberculosis- newer trends in the diagnostic
modalities
Dr Anusha Rao P
PGY 2
CAIMS
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Varied incidence depending on the SES and the environment.
1% among the patients at gynec OP in India.
5 – 10 % amongst the patients with infertility.
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Pathogenesis
• Mycobacterium tuberculosis of human type.
• Rarely M.bovine.
• Almost always of secondary type.
• Fallopian tubes are invariably the primary sites of pelvic TB.
• Mode of spread : Hematogenous (90%)
Lymphatic/ Direct
Ascending
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ORGAN FREQUENCY
Fallopian tubes 90-100%
Endometrium 50-60%
Ovaries 20-30%
Cervix 5-15%
Vulva and Vagina 1%
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Pelvic peritonitis:
• Wet type
• Dry type
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Microscopic appearance of the granuloma:
• Multinucleated giant cells, Langhans cells
• Chr. Inflammatory cells
• Epithelioid cells
• Central area of caseation necrosis.
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Clinical features
• High index of suspicion• 20% give family history• 30-50% might have had some form of TB and give H/o
ATT.
Symptomatology: • Systemic• Infertility• Menstrual disturbances• Abdominal swelling , postcoital bleeding, vaginal
discharge,dyspareunia
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Signs:• Normal 35- 50 %• Abdominal mass• Pelvic mass• Adnexal mass/ tenderness• Ascites• Excessive Vaginal discharge• Ulcer vagina/ cervix/ vulva
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Investigations
• Culture : Gold standard, but very low positive rates.BD MGIT: more rapid and sensitive than other
methods of culture.
• Egg based media 3-8 weeks eg Lowenstein Jensen media
• Agar based < 3 weekseg- BACTEC medium
• BacT/ALERT 3D MBmodified Middlebrook 7H9 broth with supplements
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Tuberculin (Mantoux) tests0.1 ml PPD is injected intradermally
• Not 100 % sensitive or specific
• A positive test is read as discrete wheal > 10mm between 48 -78 hrs
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• Mantoux test in women with laparoscopicallydiagnosed tuberculosis
sensitivity - 55% specificity - 80%
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• Blood
• Chest X ray
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• Diagnostic uterine curettage: Optimal time of sampling, at the end of the menstrual cycle or within 12 hrs after the onset of menstrual flow.
HPE
culture in L-J media
AFB microscopy
Nucleic acid amplification (PCR)
Guinea pig inoculation
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Endometrial curettage
• Frequent first diagnostic test
• False negetive because of sampling errors
• Diagnosis by either MTB isolation or histological Granulomata.
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Negative biopsy does not exclude GTB
• Cornual curettage yields atleast 50% possibility of rapid histological diagnosis
• positive culture was seen in 25 % cases of Tb endometritis.
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• Menstrual blood: low sensitivity
- collected on D2 of her cycle
Mycobacterial culture, nucleic acid amplification and guinea pig inoculation.
Positive report supports the diagnosis but a negative report doesn’t rule out the infection.
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• Sputum and urine
• Lymph node biopsy
• CT/ MRI abdominal, pelvic
• Laparoscopy
• Endoovarian tissue biopsis and Pelvic aspiration fluids.
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Hysterosalpingography (HSG)• Vascular or lymphatic extravasation of the dye• Rigid (lead-pipe) tubes with nodulations• Tobacco-pouch appearance• Beaded appearance of the tube• Distal tube obstruction• Coiling/ calcified shadows• Bilateral cornual block• Irregular, honey-comb appearance of the uterine
cavity
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Rigid pipe
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Calcification with irregular uterine cavity
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Clubbing of ampulla
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Intravasation of dye
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Filling defect
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Tobacco pouch
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Hysteroscopysmall cavity with adhesion
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3D ultrasound fundal adhesions..
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Detection and identification of mycobacteria directlyfrom clinical samples
• Genotypic Methods :
• PCR
• NAA
Dr.T.V.Rao MD 27
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•PCR-based genetic tests
• Detection is based on multiplication not of whole bacilli, as in culture, but of their genetic material, chromosomal DNA or ribosomal RNA.
• In principle, from one target sequence, of one bacillus, the reaction can produce millions of copies and thus yield a positive result
Dr.T.V.Rao MD 28
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Sensitivity 85-95%,specificity 90-97%
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NAA techniques
• Gen –probe M.tuberculosis test –transcription mediated amplification of rRNA
good in smear positive samples
• Ampiclor test – PCR amplification of DNA
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Different types of PCR
• Real time PCReg: Mycosure Dr.Lal Pathlabdetects both mycobacterium tuberculosis and Non tuberculosis mycobacteria
• Multiplex PCReg TB PCR –SRL laboratorydetects mycobacteria tuberculosis complex
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• Nested DNA PCR
Eg. Reliance laboratorytargets IS61110 gene region in TB DNA
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• False positive PCR may be due to NTM
• False negative due tosampling errorblood contamination paucibacillary specimensPCR inhibitorsineffective primers
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• new class of in vitro assay that measure interferon (IFN-γ) released by sensitized T cells after stimulation by M. tuberculosis antigens.
• Measures immune reactivity to M.tb.
Quantiferon-GOLD
35
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Conventional methods for the diagnosis of TB include microscopy and culture.Ziehl-Neelsen (ZN) staining of AFB requires 104-106
bacilli/ml of tissue or fluid specimens to give a positive result.Although culture for Mycobacterium is more sensitive, it still needs 10-100 bacilli/ml of sample for the diagnostic yield and requires 2-4 weeks for the growthof Mycobacterium. A diagnostic method that is less time-consuming and at the same time has high sensitivity and specificity istherefore desirable.
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Nucleic acid amplification (NAA) tests
represent a major advance in the diagnosis of
TB.
PCR based methods: very useful for rapid diagnosis and require bacteria as less as
10 bacteria/ ml of the specimen.
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DNA-PCR unable to differentiate between viable and non viable organisms,
But is reliable even in the absence of activity at the site of sample collection, with the primary foci elsewhere in the body..hence is useful in the detection of early tubercular involvement.
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• Reverse Transcriptase PCR (RT PCR): detection of viable organisms possible because bacterial mRNA with a mean half-life of 3-5 minutes is more prone for destruction than genomic DNA, hence positive mRNA signal would indicate the presence of viable organisms.
• STN RT-PCR more sensitive as it can detect even a single copy of MTB gene
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Results from a study by Srivastava et al as published in the Journal of Human Reproductive Sciences / Volume
7 / Issue 1 / Jan - Mar 2014
Total samples Total positive samples
Only Microscopy +
Only culture + Only PCR +
227 133 (58.5%) 0 7 (5.2%) 115 (86.4%)
Microscopy +Culture +
Microscopy +PCR +
Microscopy +Culture +PCR +
0 11 (8.2%) 2 (1.5%)
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• Overall sensitivity:
PCR assay: 31.3%
Microscopy: 5.1%
Culture: 4.2%
HPE: 2.4%
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Differential diagnosis:
• Pyogenic tubo-ovarian mass
• Pelvic endometriosis
• Adherent ovarian cyst
• Chronic disturbed ectopic pregnancy