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

Michel E. Rivlin, MD

Disclosures

January 26, 2016

Response to drug therapy is excellent for all forms of genital tuberculosis. Surgery is reserved for large tubo-ovarian abscesses, abscesses refractory to antituberculosis treatment, persistent adnexal masses, persistent pain, and drug resistance. Multidrug-resistant strains of tuberculosis (MDR-TB) are defined as those resistant to at least isoniazid and rifampin. The leading risk factors for these strains are coexistent HIV, improper drug selection, inappropriate or incomplete treatment, patient noncompliance with the treatment, or infection spread by an individual who carries a resistant strain.

Because sensitivity results may take 6-8 weeks, treatment is started with multidrug regimens that are modified when results become available. If genital tuberculosis is encountered unexpectedly at surgery (as in this case), only biopsy should be performed, as procedures after 3-4 months of drug therapy are technically easier and less prone to complications (especially fistulae). For the same reason, surgery should be delayed until an adequate course of medical therapy has been delivered, whenever possible. Drug therapy should be prolonged for 18-24 months as required.[3] In adults, however, most forms of extrapulmonary tuberculosis can be cured with 6 months of chemotherapy, although the clinical response should guide decisions on treatment duration.[7]

In this patient, treatment with rifampin, ethambutol, isoniazid, and pyrazinamide was promptly initiated. Characteristically after laparotomy, the ascites did not recur and her clinical progress was satisfactory. Two months after surgery, she had made remarkable progress. Treatment was continued with the same drugs, as the organism was sensitive to all four agents. Her prognosis was quite good, but unfortunately her prospects for spontaneous pregnancy were poor, as evidenced by the massive scarring in and around her fallopian tubes. The rarity of a successful uterine pregnancy with genital tuberculosis is borne out by a report from India in which nine of 56 treated patients conceived; of these, eight suffered spontaneous abortions and only one had a successful pregnancy.[8] In these cases, however, successful pregnancies have been reported with in vitro fertilization.[5]

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