CASE 14163 Published on 29.12.2016

Female genital tuberculosis

Section

Genital (female) imaging

Case Type

Clinical Cases

Authors

Tonolini Massimo, MD; Bonzini Miriam, MD.

"Luigi Sacco" University Hospital,Radiology Department; Via G.B. Grassi 74 20157 Milan, Italy; Email:mtonolini@sirm.org

Patient

58 years, female

Categories

Area of Interest Lung, Mediastinum, Genital / Reproductive system female ; Imaging Technique CT

Procedure Diagnostic procedure ; Special Focus Infection ;

Show more Show less

Download as PDF Print Show related cases Notify admin

Clinical History

A postmenopausal G9 woman with unremarkable past medical history, and recently discharged from another Hospital after treatment of urinary tract infection, was sent by another gynecologist to our emergency department because of suspected pyometra and indeterminate adnexal masses. No significant physical findings were seen, in particular fever or vaginal discharge.

Imaging Findings

Further questioning revealed that the patient's husband was treated for tuberculosis a year earlier in their native country (Albania).
Initial CT (Figs.1, 2) showed bilateral adnexal enlargement with 20-24 Hounsfield units internal attenuation and peripheral enhancement, dilated uterine cavity by similar hypoattenuating content with thin endometrial enhancement, and omental infiltration. Ascites, adenopathies, abnormalities of upper abdominal and urinary organs were absent. Scattered infracentimetric non-cavitated nodules in both upper lung lobes and a partially necrotic mediastinal adenopathy were seen.
QuantiFERON-TB assay tested positive for tubercular infection, but the purulent-necrotic material from the endometrial biopsy did not harbour microscopically detectable organisms. After the start of anti-tubercular combination therapy, polymerase-chain reaction (PCR) for Mycobacteria on DNA extracted from endometrial biopsy samples confirmed diagnosis of genital tuberculosis.
Early follow-up CT (Figs.3, 4) showed minimal decrease of some lung nodules, reduced uterine dilatation with persistent endometrial enhancement, stable adnexal lesions and omental infiltration.

Discussion

Despite effective therapies, tuberculosis remains a major health problem, particularly in regions with a concentrated population, poor sanitation and unfavourable social and economic conditions. During the last decade, tuberculosis had a resurgence because of migrations, the HIV epidemic and drug-resistant bacilli. After the lymph nodes, urogenital tuberculosis (UGTB) is the second commonest extrapulmonary pattern, accounting for 27% of cases. Albeit the vast majority of cases occur in developing countries, UGTB is occasionally encountered in non-endemic regions, particularly in immigrants and immunosuppressed individuals [1-4].
UGTB results from hematogenous spread and subsequent reactivation of Mycobacterium tuberculosis, develops several (up to 20-25) years after primary infection and therefore presents in adulthood, often without history or radiographic evidence of lung infection. Sexual transmission rarely occurs in partners of patients with UGTB. Isolated genital involvement is an uncommon (5%) UGTB pattern which generally affects childbearing-age women and manifests with chronic pelvic pain, amenorrhea or abnormal menstruation; microscopic haematuria, irritative voiding and constitutional symptoms often coexist. UGTB accounts for 1%, 7.4% and 18% of infertile women in the USA, Turkey and India, respectively. Diagnostic confirmation relies on demonstrating Mycobacteria in urine, cultures and polymerase chain reaction assays [4-6].
Female UGTB affects the fallopian tubes (in almost 95% of patients), endometrium (50-60%), ovaries (20-30%), cervix (5-15%), myometrium (2.5%), and vulva/vagina (1%) in descending order of frequency [1, 5, 7].
Traditionally, hysterosalpingography revealed deformity and obliteration of the endometrial cavity, multifocal strictures of the fallopian tubes. Currently, using multiplanar reconstructions cross-sectional CT imaging clearly elucidates the genital organs: UGTB shows up as uni- or bilateral dilated, pus-filled fallopian tubes or complex thick-walled, internally hypoattenuating adnexal masses with septations or fluid-debris level; the latter appearance closely resembles pyogenic tubo-ovarian abscesses and may be misinterpreted as ovarian tumours. From the adnexa, trans-serosal spread of infection leads to peritonitis and endometritis, with corresponding appearance of dilated endometrial cavity with hypodense fluid content. Tuberculosis is suggested over pyogenic infection by the presence of concurrent disease localizations in the lungs, mediastinal or neck lymph nodes, peritoneum and omentum, urinary tract, abdominal nodes, liver and spleen, occasionally central nervous system or spine [7-14].
To prevent unnecessary surgery, aware radiologists should include UGTB in the differential diagnosis of adnexal masses, particularly in HIV-positive young adult females, even when ascites and omental changes suggesting carcinomatosis are present [15, 16].
UGTB requires prolonged therapy with multidrug regimens analogous to those used to treat lung tuberculosis [1, 3-6].

Differential Diagnosis List

Female genital (adnexal and endometrial) tuberculosis

Pyogenic endometritis and tubo-ovarian abscesses in pelvic inflammatory disease

Actinomycosis

Cystic ovarian tumour

Krukemberg type metastases

Complicated (abscessual) diverticulitis or appendicitis

Final Diagnosis

Female genital (adnexal and endometrial) tuberculosis

References

[1] Zajaczkowski T (2012) Genitourinary tuberculosis: historical and basic science review: past and present. Cent European J Urol 65:182-187 (PMID: 24578959)

[2] Figueiredo AA, Lucon AM, Junior RF, et al. (2008) Epidemiology of urogenital tuberculosis worldwide. Int J Urol 15:827-832 (PMID: 18637157)

[3] Figueiredo AA, Lucon AM (2008) Urogenital tuberculosis: update and review of 8961 cases from the world literature. Rev Urol 10:207-217 (PMID: 18836557)

[4] Abbara A, Davidson RN (2011) Etiology and management of genitourinary tuberculosis. Nat Rev Urol 8:678-688 (PMID: 22157940)

[5] Turkmen IC, Bassullu N, Comunoglu C, et al. (2012) Female genital system tuberculosis: a retrospective clinicopathological study of 1,548 cases in Turkish women. Arch Gynecol Obstet 286:379-384 (PMID: 22410957)

[6] Figueiredo AA, Lucon AM, Gomes CM, et al. (2008) Urogenital tuberculosis: patient classification in seven different groups according to clinical and radiological presentation. Int Braz J Urol 34:422-432; discussion 432 (PMID: 18778493)

[7] Sharma JB, Karmakar D, Hari S, et al. (2011) Magnetic resonance imaging findings among women with tubercular tubo-ovarian masses. Int J Gynaecol Obstet 113:76-80 (PMID: 21247567)

[8] Burrill J, Williams CJ, Bain G, et al. (2007) Tuberculosis: a radiologic review. Radiographics 27:1255-1273 (PMID: 17848689)

[9] Zissin R, Gayer G, Chowers M, et al (2001) Computerized tomography findings of abdominal tuberculosis: report of 19 cases. Isr Med Assoc J 3:414-418 (PMID: 11433633)

[10] Harisinghani MG, McLoud TC, Shepard JA, et al. (2000) Tuberculosis from head to toe. Radiographics 20:449-470 (PMID: 10715343)

[11] Engin G, Acunas B, Acunas G, et al (2000) maging of extrapulmonary tuberculosis. Radiographics 20:471-488 (PMID: 10715344)

[12] Jung YY, Kim JK, Cho KS (2005) Genitourinary tuberculosis: comprehensive cross-sectional imaging. AJR Am J Roentgenol 184:143-150 (PMID: 15615965)

[13] Bennett GL, Slywotzky CM, Giovanniello G (2002) Gynecologic causes of acute pelvic pain: spectrum of CT findings. Radiographics 22:785-801 (PMID: 12110710)

[14] Cano Alonso R, Borruel Nacenta S, Diez Martinez P, et al. (2009) Role of multidetector CT in the management of acute female pelvic disease. Emerg Radiol 16:453-472 (PMID: 19326153)

[15] Hasanzadeh M, Naderi HR, Hoshyar AH, et al. (2014) Female genital tract tuberculosis presenting as ovarian cancer. J Res Med Sci 19:184-189 (PMID: 24778675)

[16] Denue BA, Kwayabura SA, Ngadda HA (2014) Ovarian tuberculosis masquerading as ovarian cancer in HIV infected patient: a plea to avoid unnecessary surgery. Afr Med J 19:210 (PMID: 25829975)

Case information

URL:	https://www.eurorad.org/case/14163
DOI:	10.1594/EURORAD/CASE.14163
ISSN:	1563-4086

License

This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.

Figure 1

Initial contrast-enhanced multidetector CT (thoracic images)

In both upper lobes, scattered infracentimetric non-cavitated nodules were present, best appreciated with maximum-intensity projection (MIP) reconstruction (b).

Additionally, a sizeable (3 cm) partially necrotic mediastinal adenopathy (thick arrow) was present. No pleural and pericardial abnormalities.

Figure 2

Initial contrast-enhanced multidetector CT (abdomino-pelvic images)

Multiplanar post-contrast images showed bilateral adnexal enlargement (+) with hypoattenuating (20-24 Hounsfield units, HU) content and uniform peripheral enhancement. No ascites and adenopathies were present.

Bilateral adnexal enlargement (+) with hypoattenuating (20-24 HU) content and peripheral enhancement. Dilated uterine cavity (*) by similar hypoattenuating content with thin endometrial enhancement (thin arrows).

Dilated uterine cavity (*) by similar hypoattenuating content with thin endometrial enhancement (thin arrows).

Additionally, omental hazy infiltrate (arrowhead) was present. Note thin endometrial enhancement (thin arrows), 4 cm right-sided adnexal enlargement (+) with hypoattenuating (20-24 HU) content and peripheral enhancement.

Additionally, moderate omental hazy infiltrate (arrowheads) was present.

Figure 3

Follow-up (1 month) contrast-enhanced multidetector CT (thoracic images)

Repeated CT including MIP reconstuction (b) showed minimal size decrease of some of the non-cavitated nodules scattered in both upper lung lobes.

The solitary mediastinal adenopathy (thick arrow) showed stable size and persistent necrosis.

Figure 4

Follow-up (1 month) contrast-enhanced multidetector CT (abdomino-pelvic images)

Multiplanar post-contrast images showed decreased uterine dilatation (*) compared to Fig.1 with persistent endometrial enhancement (thin arrow), unchanged adnexal lesions (+) and omental infiltration (thick arrow).

Multiplanar post-contrast images showed decreased uterine dilatation (*) compared to Fig.1 with persistent endometrial enhancement (thin arrow), unchanged adnexal lesions (+).