Volume. 35, No. 2 july. 2011 - The Chest and Heart Association of ...

Chest & Heart Journal Vol. 35, No.-2, July 2011pelvic infections 8,9,10 and occurs in 10% cases ofpulmonary TB 8,10 . The first reported case ofgynaecological TB was described by Morgagni in1744 11 .The prevalence of female GTB is largelyunderestimated as the disease often remains silentor may present with non-specificsymptomatology 3 . However a rising incidence,partly as a result of HIV pandemic 10,12,13 andemergence of resistant strains has beenreported 8,13 . Majority of patients are in thereproductive age group 5,8,9,14, but older womenare also known to harbour it 15 .This silent invader of genital tract tends to creatediagnostic dilemmas 7,13 & remains a challenge forthe clinicians. As there is no gold standard test 7 , ahigh index of clinical suspicion aided by a numberof investigations may help to reach to a definitediagnosis. A combined approach involving arespiratory physician and gynaecologist may helpto achieve the optimum goal in diagnosis,treatment and follow-up particularly in dealing withthe multi-drug resistant TB (MDR-TB) cases. Anearly diagnosis is important otherwise many womenin their sexual prime are rendered infertile due toGTB 9 . The chances of pregnancy have so far beenpoor (5%) even after the completion of treatment 8 .Incidence :The exact incidence of female GTB is not knownpartly because more often the disease remainssilent and in addition there are lack of reliableconfirmatory investigations 10 . In developedcountries, such as USA, Australia and WesternEuropean countries, the incidence is les than 1percent 16,17 but the incidence in some Africancountries is as high as 15-19 percent 18,19 . Theglobal prevalence of genital tuberculosis isestimated to be 8-10 million cases 20 with a risingtrend in some developing countries 12 . Increase inthe trend of this disease may be partly due to anoverall rise in tuberculosis cases 8,10 . The othercontributory factors may be HIV infection andemergence of drug resistant forms 8,13 . It isimportant to mention that, the incidence of TBhas decreased significantly worldwide during thelast 30 years 22 . However, the pandemic of HIVhas altered its incidence, morbidity and mortalityin less developed countries 12 .Situation in Bangladesh (BD) :According to WHO, Bangladesh ranks sixth amongcountries with high TB burden 23,24 . The estimatedprevalence and incidence rates of all forms of TBincluding HIV were respectively 411 and 225 per100,000 population and mortality rate excludingHIV was 43 per 100,000 in 2010 2 . But according toa nationwide Tuberculosis Disease – cum –Infection Prevalence Survey 2007-09 – a steepdecline in the number of TB cases among urbanpopulation has been registered 24 . The prevalenceof female GTB is not known but there is a risk ofresurgence of TB as the HIV burden has movedfrom low prevalence to ‘concentrated epidemic’following the publication of the HIV sero surveyresults of more than 5 percent among injectingdrug users 25 . Data from national drug resistancesurveys indicate low levels of MDR-TB. Isolatedsurvey have indicated that MDR-TB rates amongnewly diagnosed cases between 3% and 15.4% 23 .The proportion of HIV positive individuals amongTB cases has been estimated to be 0.1% and HIVprevalence is 7% among injecting drug users 23 .Impact of female GTB on reproductive health :Female GTB is one of the major causes for severetubal disease leading to infertility 3 . There is awealth of literature on GTB and infertility 7 , beingfirst shown by Malkani et al. 26 . When TB affectsgenital organs of young females, it producesdevastating effects by causing irreversible damageto the fallopian tube resulting in infertility whichis difficult to cure both by medical and surgicalmethods 27,28 . Minimal damage may lead to ectopicpregnancy and extensive damage may lead tocomplete tubal occlusion 15 . Peritubal adhesionsand tubo-ovarian mass have been found in 47.2%of cases 29 , Various grades of intra-uterine adhesion(Asherman’s syndrome) or nonreceptiveednometrium have been reported in associationwith GTB 30 .However, the average worldwide incidence offemale genital TB in infertile population has beenreported as 5-10% 31,32 . Despite the advances inchemotherapy, with the WHO’s recommendedDOTS strategy 33 , pregnancy and live birth afterdiagnosis of GTB has been reported to be low andwhen it did occur was more likely to be an ectopicpregnancy or resulted in a spontaneous abortion34,35 . Overall, the conception rate among women114