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