Genital Tuberculosis: A New Challenge in an Old Disease

Abstract

In this issue of the Southern Medical Journal a case of genital tuberculosis (GTB) was reported in a young African refugee woman presenting with primary infertility intermittent pelvic pain and menstrual irregularities. Tuberculosis (TB) is a rare disease in some developed countries but it is a frequent cause of chronic pelvic inflammatory disease (PID) and infertility in other parts of the world. GTB is common in women of childbearing age from developing countries. However GTB is not frequently reported in Southeast Asia including Malaysia which is surprising due to the remarkably high incidence of TB in these areas. This patients HIV status was unknown; however she came from a region that is undoubtedly one of the most affected by the HIV epidemic and the global resurgence of TB. Therefore the incidence of GTB may be higher than one might imagine especially among young women living with HIV/AIDS. It is imperative that clinicians have a high index of suspicion for GTB in young immigrant women presenting with unexplained infertility nonspecific menstrual disturbances/ gynecological problems pain or abdominal distension. Diagnosing GTB remains a challenge for clinicians and is based on clinical grounds and confirmed by laboratory investigations such as a TST. Polymerase chain reaction (PCR) is a rapid sensitive and specific molecular technique for detecting GTB and can be used in combination with other available methods. This technique requires invasively obtained biopsy material and therefore noninvasively obtained samples (eg menstrual blood) are beneficial. Interestingly a few other tests such as the detection of Mycobacterium tuberculosis (MTB) antigens using enzyme-linked immunosorbent assay (ELISA) techniqueor the elevation of serum CA-125 levels have shown promising results. However more studies are warranted to elucidate their usefulness for routine diagnosis. Once GTB is confirmed treatment is straightforward and is basically the same regimen used for pulmonary TB. After completion of treatment 95% of patients are considered cured and the patient should be followed by x-ray urine culture and endometrial sampling.10 Empirical treatment is the other option for treating GTB in women who have the characteristic changes on hysterosalpingogram a positive tuberculin skin test and a strong contact history although such cases lack the classic diagnostic criteria.11 This case report highlights the importance of TB as one of the major causative agents of infertility especially in resource-poor countries. A substantial influx of refugees or migrants from TB-endemic countries may cause a significant increase in the incidence of TB/GTB in the host countries and may potentially impact the future of TB control. (full-text)