Obstetrics & Gynaecology Forum Volume 29 | Issue 3 | 2019

O&G Forum 2019; 29: 31 - 32 CASE REPORT amenorrhea and infertility as a result of FGTB. Case Report A 28 year old, nulliparous woman, presents with secondary amen- orrhea and primary infertility. She last had her period seven months before consultation. Prior periods had been normal, regular and would last for four days. There were no symptoms of pregnancy, or history of headache or blurring of vision, no contraception use and no history of drug use. She was sexually active and had been mar- ried for three years with no children or previous pregnancies. The rest of her history was non-contributory. She had been diagnosed with HIV 2-3 years prior and was currently on highly active antiret- roviral treatment (HAART). Her pap smear 2 years ago was normal. She gave a history of myomectomy (four years ago) for abnormal uterine bleeding secondary to uterine fibroids. The patient had normal general examination, with a BMI of 27. She did not have hirsutism. Her chest was clear upon examination. Abdominal examination was soft, non-tender with no masses. CNS was intact. Differential diagnosis was pregnancy, premature ovarian failure/primary ovarian insufficiency, drugs or pituitary tumours. However, pregnancy test was negative and pelvic ultrasound was normal and basic bloods were taken. She was given Provera chal- lenge of 10 mg daily for 10 days after which she noticed small red mucous-like substance following one week of the Provera course. This was considered as a negative progesterone withdrawal chal- lenge. However, she was still amenorrhoeic. Her laboratory results showed that her serum FSH was 1.9U/L (Normal ranges - Follic- ular phase 3.0-8.1U/L, midcycle 2.6-16.7U/L, Luteal phase 1.4- 5.5U/L); serum LH was 2.8U/L (Normal ranges - Follicular phase 2.9-21.7U/L, midcycle 18.1-90.2U/L, Luteal phase 0.8-16.2U/L); serum progesterone was 32.1nmol/l (Normal ranges - Follicular phase 0.3-1.0nmol/l, Luteal phase 3.8-50.5nmol/l); serum oestro- gen: 555pmol/l (Normal ranges - Follicular phase 76.7-921pmol/l, midcycle 139-2382pmol/l, Luteal phase 77-1145pmol/l); prolactin was 13ng/ml (Normal range - 2.8-29.2ng/ml) and TFTs were nor- mal. Upon hysteroscopy, extensive intra-uterine adhesions were noted and curetting and biopsy was taken, followed by adhesiolysis and an intra-uterine device inserted (Copper T). Histology showed extensive granulomatous inflammation with central micro-abscess formation. The differential diagnosis was then genital TB or schis- tosomiasis. The acid fast bacilli (AFB) test on the curettings was negative but the diagnosis of genital TB was most likely in view of her HIV status. The patient was then managed as genital TB. Following extensive counselling, the patient was started on anti-TB treatment for nine months. Her periods resumed on the fifth month of TB treatment. Discussion The incidence of genital TB is increasing especially in developing countries. 6 It has been associated with HIV infection and TB mul- tidrug resistance. Approximately 5-13% of 20 – 40 year old women with infertility are due to genital TB. 6 In our case, the patient was 28 years old with infertility and experiencing amenorrhea. Suspected cases of FGTB therefore require optimised methods for diagnosis and early detection will prevent further genital tract damage and sterility. 6 Although our patient was negative for AFB, she was still diagnosed with FGTB on the overall clinical picture. This can be due to the paucibacillary state of TB as the specimen smears require a high number of bacilli in order to test positive. 6,7 Biswas et al., 2003 was able to detect MTB in cultures which were not identified by the Ziehl-Neelsen stain for AFB for the diagnosis of FGTB. 8 Co-infection with HIV, facilitates rapid spread of TB as a result of reduced immunity. 9 In developing areas such as SA, there is a high burden of HIV infection and patients have an increased sus- ceptibility to TB. Duggal et al., 2009 presented a case of an adoles- cent with normal chest x-ray, irregular menstrual cycle and was lat- er diagnosed with FGTB. 9 Histopathology revealed granulomas and the Ziehl-Neelsen stain was positive for acid and alcohol fast bacilli (AAFB). 9 Following TB treatment, her menstrual cycle returned to normal however further test showed she was also HIV positive. Female genital tract is a vulnerable site for TB infection and clinical signs often occur at late stage leading to infertility. 10 Dam- age to the fallopian tube and endometrium as a result of the in- fection are seen in women with FGTB. 10 Irreversible damage occur resulting in infertility. 11 Differential diagnosis depending on clin- ical signs and symptoms include infections, ectopic pregnancies, syphilis, cysts, schistosomiasis and cancer amongst several others. 4 Datta et al., 2018 showed that IFNγ and IL2 are elevated in FGTB and can be possibly used as a clinical indicator. 10 Djuwantono et al., 2017 assessed three cases with irregular menstrual cycles and infertility. 12 Laparoscopy and PCR suggested FGTB. TB treatment was administrated with positive clinical outcomes. 12 In our case, the patient’s menstrual cycle resumed following five months of TB treatment. Conclusion FGTB should be considered in women presenting with various menstrual abnormalities especially in high burden countries, par- ticularly in the backdrop of HIV. Early diagnosis and treatment of FGTB are imperative in order to prevent severe damage and subse- quent fertility issues. Acknowledgements We acknowledge Dr C. Tiloke for the assistance in the manuscript preparations. References 1. Heunis JC, Kigozi NG, Chikobvu P, Botha S, van Rensburg HCJD. Risk factors for mortality in TB patients: a 10-year electronic record review in a South African province. BMC Public Health 2017; 17. 2. Botha M, Van der Merwe FH. Female genital tuberculosis. SA Fam Pract 2008; 50: 12-16. 3. Ahmed S, Shaha DR, Begum P, Akter T. Female Genital Tuberculosis. Faridpur Med Coll J 2018; 13: 53-55. 4. Sharma JB. Current Diagnosis and Management of Female Genital Tuberculosis. J Obstet Gynecol India 2015; 65: 362-371. 5. Sotgiu G, Centis R, D’ambrosio L, Battista Migliori GB. Tuberculosis Treatment and Drug Regimens. Cold Spring Harb Perspect Med 2015; 5: a017822. 6. Usharani B, Muthuraj M, Radhakrishnan B, James JB, Govindarajan S, Raman KV. Molecular Epidemiology of Female Genital Tuberculosis leading to infertility. Int J Curr Microbiol App Sci 2016; 5: 731-740. 7. Butt T, Ahmad RN, Kazmi SY, Afzal RK, Mahmood A. An update on the diagnosis of tuberculosis. J Coll Physicians Surg Pak 2003; 13: 728-734. 8. Biswas D, Agrawal M, Ali A, Bhargava R. Anti ES-31/41 antibodies: A potential tool in the serodiagnosis of extra-pulmonary Tuberculosis. Indian J Tuberc 2003; 50: 203-207. 9. Duggal S, Duggal N, Hans C, Mahajan RK. Female genital TB and HIV co-infection. Indian J Med Microbiol 2009; 27: 361-363. 10. Datta A, Chaudhuri AR, Chatterjee S, Chowdhury RG, Bhattacharya B. Role of endometrial cytokines of the female genital tract tuberculosis in the context of infertility. BLDE Univ J Health Sci 2018; 3: 24-30. 11. Eftekhar M, Pourmasumi S, Sabeti P, Aflatoonian A and Sheikhha MH. Mycobacterium tuberculosis infection in women with unexplained infertility. Int J Reprod BioMed 2015; 13: 749-754. 12. Djuwantono T, Permadi W, Septiani L, Faried A, Halim D, Parwati I. Female genital tuberculosis and infertility: serial cases report in Bandung, Indonesia and literature review. BMC Res Notes 2017; 10. OBSTETRICS & GYNAECOLOGY FORUM 2019 | ISSUE 3 | 32