An 18-Year-Old With Nausea and Increased Abdominal Girth

Michel E. Rivlin, MD

Disclosures

January 26, 2016

Discussion

Tuberculosis is a major world health problem, with a global prevalence estimated at 32%. In the United States, the percentage of cases occurring among foreign-born persons was 53% in 2003. Female genital tuberculosis is not uncommon in parts of the world where pulmonary tuberculosis is widespread. Tuberculosis is also associated with the HIV epidemic; in particular, extrapulmonary tuberculosis can be found in more than 50% of patients with concurrent AIDS.[1,2]

Female genital tract infection may be contracted by hematogenous spread from a pulmonary nidus (the fallopian tube is the predominant site of infection) or the spread may be from gastrointestinal infection, characteristically from the ileocecal region by lymphatic spread to the right tube. Characteristically, the involvement of the fallopian tubes is bilateral (although asymmetric), with the tubes becoming thickened, swollen, and often with a roughened surface and adhesions. The tubes may also become obstructed, most often at the junction of the ampullary region with the isthmus and with multiple constrictions throughout the tubal length.

The appearance of the tubes varies; in severe cases, they may be distended with caseous material. In milder cases, they may have only tubercles on the serosa. The fimbrial end of the tube is usually spared and remains patent with the fimbria everted, which produces the "tobacco pouch" appearance.[3] Distal tubal disease usually appears secondary to peritubal adhesions. These adhesions disrupt the delicate anatomical relationship between the tube and the ovary and interfere with normal ovulation. Spread from the tubes to the endometrium is common, but the ovaries do not usually show signs of involvement. In addition, involvement of the cervix, vagina, and vulva is uncommon. Tuberculous peritonitis is a variant of genital tuberculosis that results from initial miliary dissemination during primary bacteremia or secondarily during reactivation of pulmonary or extrapulmonary disease. Genital and peritoneal diseases are coexistent in up to 50% of cases.

The characteristic tuberculous granuloma consists of a central area of caseous necrosis surrounded by concentric layers of modified epithelial cells and with multiple Langerhans giant cells, all of which is surrounded by a peripheral zone of lymphocytes, monocytes, and fibroblasts. Calcified lymph nodes or irregular calcifications of the adnexa may be noted.

The clinical manifestations of genital/peritoneal tuberculosis include abdominal pain, abdominal swelling, persistent low-grade fever, weight loss, malaise, and fatigue. Menstrual disturbances initially include increased and irregular bleeding. Amenorrhea is usually evidence of advanced endometritis, which is secondary to spread from a primary focus in the tubes. Infertility is the most common complaint, and up to 85% of women with tuberculous salpingitis or genital tuberculosis never get pregnant.

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