Downloaded from http://journals.tums.ac.ir/ on Wednesday, October 17, 2012  E- mail:[email protected] 9968604341 + 91 Tel: India 110002, andMedical College associated Azad Maulana , and ofObstetrics Department Centre, Biology Reproductive & IVF M.D. Prasad, Sudha Dr. Correspondence: congenital anomalies (1,2). or puerperal infections foreign bodies, due to malignantcaused cervicallesions(1). Itmay alsobe benign/ tochronicatrophiccervicitis,or secondary canal of thecervical occlusion causedby usually an oldage It isusually cavity. disease. Theconditionis Pyometra is theaccumulation of intheuterine Introduction Keywords: hysterosalpingography. post- with pyometra patients presenting in infertile genital tuberculosis,particularly precision’ gene detection methods (e.g.mRNA) in c ‘high- suspicion and of clinical high degree combination of that a We conclude tubercular therapy. Genital tuberculosis wasconfirmed by pa disappeared and tubo-ovarian masses Pyometra and based RT-PCRfordetectionof diagnosis by culture, confirmationof AFB smear/ for routineand pyometra, endometrialbiopsy hysterosalpingography in aprivatehospital tenda lower withwatery discharge forthepast five days.She had history of undergoing A 25-year-old femalepresentedtotheinfertility OPD Abstract Junlo aiyadRpoutv elh Vol. 6, No. 3, September 2012 Journal of Family and Reproductive Health

A RareCaseofTuberculousPyometrainaYoungInfertile Delhi, India 2 Division of Biotechnology/Molecular2 Divisionof Diagnostics& Delhi, India; College, New 1 IVF and Reproductive Biology Centre, Department of Centre,Department Reproductive Biology IVF and Megha Singhal; M.D. Singhal; Megha

Pyometra, tuberculosis, tuberculosis, Pyometra, 1

Female ConfirmedbymRNA-basedRT-PCR Lok NayakHospital,NewDelhi- However, itisthoughtto Received July2012;RevisedandacceptedAugust2012 1,2

, Renu Tanwar; M.D. M. tuberculosis- m RNA-based RT-PCR, endometrial biopsy biopsy endometrial RT-PCR, RNA-based m RNA-based RT-PCR and thedisease resolved afteranti- specific 85Bantigengene,anti-tuberculartherapy. 1 ulture-negative cases may beuseful in diagnosisof

,

ys back. Theinterventionsincludeddrainage of Ashok Kumar; M.D. Kumar; Ashok Microbiology, NationalCent Microbiology, vaginum for 5 She of days. also had a history with the paininlower abdomen anddischargeper along foroneyear complaint ofsecondary care of our centre withprimetertiary Gynaecology and the Departmentof Clinicof Infertility oldwoman 25-year A reportedto the young Case Report revealedactiv the of and biopsy the patientrevealedpyometra discharge pervaginum Extensive-upof for5days. presented toourclinicwithinlowerabdomenand pain (4). abdominaland lower The usualsymptoms ofpyometra consistofpurulent rareinthepre-menopausal(3). be relatively agegroup with complaintsofsecondaryinfertilityandpain Obstetrics & Gynaecology, Maulana Azad Medical & Gynaecology,Maulana Obstetrics tient resumed her normal periodpost-treatment. We present a old femalecase of25-year who 1 , SudhaPrasad;M.D. re for Disease Control, re forDiseaseControl, e genital tuberculosis. 1

m RNA- 139

Downloaded from http://journals.tums.ac.ir/ on Wednesday, October 17, 2012 140 Chain Reaction(RT-PCR). Transcriptase-Polymerase and mRNA-basedReverse Reaction (PCR) BACTEC 460 TBsystems, Polymerase Chain fast bacilli(AFB)smear, on cultureandsensitivity acid the samplesent for endometrial and was biopsy inserted. A week later, the patientunderwent was catheter Foley’s sensitivity. routine cultureand for pus samplewas sent drainage andthe obtained subjected to cervicaldilatationandpyometra for72hours.Thereafter,thepatientwas eight hourly) 500mg and metronidazole-100twelve hourly mg was putonintravenousantibiotics(ciprofloxacin- patient masses1). The bilateral tubo-ovarian (Fig. up. Ultrasoundexaminationand revealedpyometra palpable andtender. were adnexal masses firm,fornices mobilein both anteverted, bulky, and seen. On pervaginum examination, was be could signs of nonpurulent. Significant examination revealedmucoid dischargewhichwas with notendernessorguarding.Perspeculum abdomensoft afebrile. The was she was stable and was married Her generalconditionwas fortenyears. She medical in her history. not reported was therapy anti-tubercular of or history Exposure totuberculosis backwhichwasmanaged one year conservatively. ofectopicpregnancy (IUI). Shealsohadahistory Inseminationwith Intra-Uterine ovulation induction of threecycles was done.Thisfollowedby inwhichbilateralsalpingostomy ago forinfertility years seven laparoscopy had undergone The patient temperature symptoms. orotherprevioussystemic fatigue, lack ofappetiteandeveningrise loss, or bowelcomplaints.reported noweight She ago. of There was fever, vomiting, no history urinary (HSG)fivedays undergoing hysterosalpingography

Initial pus samples sent for routine bacterial Initial pussamplessent forroutine hospitalized forcompletework- The patientwas o.6 o ,Spebr21 Journal of Family and Reproductive Health Vol. 6, No. 3, September 2012 Figure 2: picturesdepicting (a)py a b

Singhal et al. et al. Singhal

of thepatientwasuneventful. doses ofINHandRMPfor4months. Thefollow-up same the months,by PZA) 1500mgfor 2 followed ethambutol (E,EMB)800mg(Z, andpyrazinamide mg,INH) 300 RMP) 450mg,isoniazid (H, The treatmenttherapy. comprised of rifampicin (R, (5,6). recently us reported by per theprotocol when testedas bp region of 85B antigengene of of MPB64geneandmRNA-based RT-PCRfor216 tested positive inDNA-basedPCR for 240bpregion however,endometrialnegative. Significantly sample pathogen. Also,AFBsmearturned andculture significant culture didnotshowgrowthofany resulting from haematogenous spread from thedistant to aprimary focus secondary elsewhere inthebody, the pastthatflared-upafterhysterosalpingography. may t have hadanunderlying thatthepatient wasavailable,butitlikely history endometrialdiagnosis of mRNA-based RT-PCRreportsconfirmedthe and bothPCR Subsequently, dilatation wasdone. Ultrasound revealedpyometra forwhichcervical hysterosalpingography. after sheunderwent in the lowerabdomen anddischargepervaginum least fromIndia. infertilewomenat ‘young’ ‘tuberculous’ pyometra in (2). Wehavenotcome caseof acrossany menopausalpyom tuberculous post- cases of but sporadic pyometra arerare, 0.01–0.5% to be is reported patients in gynecological of pyometra The incidence Discussion ometra and (b)bilateralT.O.masses The patientwasthenputonanti-tubercular It isbelievedthatgenita pain presented with case, thepatient In thepresent tuberculosis. Althoughno (7). Cases of tuberculous l tuberculosis is usually l tuberculosisisusually uberculosis infectionin etra have beenreported M. tuberculosis,

Downloaded from http://journals.tums.ac.ir/ on Wednesday, October 17, 2012  Delhi is greatly acknowledged. Delhi isgreatly Control, for Disease NationalCentre Biotechnology, Centre and Biology the Division of Biochemistry and assistance from staffof IVF andReproductive Technical thisstudy. giving herconsenttocarry-out for acknowledge thepatient The authorssincerely Acknowledgement which may belife-threatening. may aggravatethedisease;andresultantperitonitis diagnosis infertile patientsasit of pyometra inyoung thus be tuberculosis should rates(5,13).Genital resulted inhigherpregnancy development of thefulminant genital tuberculosishas m state such as of theart DNA PCRand/or technology, of gen reliable diagnosis and reportedthatearly (5, 12).Wehaverecently endometrial beforeproceedingforHSG biopsy pre-menstrualto do it ismandatory19% inIndia, incidence ofgenitaltuberculosisrangesbetween1– Sincethe with pyometra post-hysterosalpingography. infertilefemalesbe consideredinyoung presenting also tuberculosis, eveninAFBnegativecasesshould and hen infertile patient; unique case of pyometra ‘tuberculous’ in a‘young’ ,negative forit. whiletheotherwas revealed to endometritis. inoneofthecases Biopsy due pyometra was patients wereinfertileandpossibly the (7, 11).Both group afterovumretrieval forIVF age- tuberculous’ pyometra inthe‘reproductive’ ‘non- twocasereportsof and thereareonly reports of pyometra in ‘post-menopausal’ women; prior ectopicpregnancy. of withhistory infertility also acaseofsecondary important (2,10). cause of Our patientwas infertility women of age andisan between 18–38years young (<1%). (8,9).In80–90%cases,itaffects vulva ovaries (10–30%),and (5%) tubes endometrium(92–100%) followedby (50%), primary focus, most commonly affecting thefallopian RNA-based RT-PCR;andtreatmentbefore Junlo aiyadRpoutv elh Vol. 6, No. 3, September 2012 Journal of Family and Reproductive Health To the best of our knowledge, this is the first is the knowledge, this of our To thebest case literature showed Review ofpublished ital tuberculosisinvolving considered for differential considered for ce suspicion of genital mRNA-based diagnosistuberculousof a pyometra 1. References nothing todisclose. The authors havenoconflict of interestandhave Disclosure 2. 3. 4. 5. 6. 7. 8. 9. 13. 12. 11. 10.

acute abdomen. Int JGynecol Obstet 2006;92:145–6. uterine perforation dueto pyometra presenting asan Nuamah NM, Hamaloglu E, Konan A.Spontaneous Can Med AssocJ1966;94:1012-3. Dutton Postmenopausal WA. tuberculouspyometra. Reproductive Medicine 2001; 46: 952–6. significance? its clinical is What of The Journal Pyometra. SF,YuenPM. Chan LY,LauTK,Wong Gynecologic Oncology 1993; 50: 384–8. cancer. cervical in with a patient generalized Spontaneous perforation ofpyometra presentingas ImachiIshikawa M, S,Matsuo TanakaS, K. Reprod Biol 2012;160:215-8. diagnosis of genital tuberculosis. EurJObstet Gynecol protein genein endometrial biopsiesreliable for DS, Et al. Targeted detectionshock of 65kDaheat Prasad S,Singhal M, Negi SS,Gupta S,Singh S,Rawat Microbiol 1997;35:1161-5. detection ofviable Mycobacterium tuberculosis. JClin MR. Single-tube,reverse transcriptase nested, PCRfor YoshimoriJou NT, RB,MasonLieblingLouie GR, JS, resulting inhysterectomy. Pyometra afterovum retrieva Nikkhah-Abyaneh Z, KhulpateeaN,Aslam MF. fertility. IntJGyn Varma TR. Genital tuberculosis andsubsequent infertility. IntJGynaecolObstet1999;64:193-4. John M, Kukkady ZA. Genital tuberculosis and 2008;46:4068-70. complaints ofwomeninJ Clin India. Microbiol endometritisinfertility with tuberculous of VM, MittalS,Etal.Association Kumar P,ShahNP,Singhal A,Chauhan DS,Katoch Steril 2003;80:637–8. after ovum retrieval for in vitro fertilization.Fertil detection of pyometra at th Hofmann Ultrasound GE,Warikoo P,JacobsW. ed. London:Macmillan Edu 1st tuberculosis. Clinical N, MillerF. J,Horne Crofton Dis 1994; 75: 239-40. of the vaginain an HIVseropositive case. TuberLung Arora VK, Johri A, AroraR, Rajaram P.Tuberculosis Obstet1991;35:1-11. FertilSteril2010;93:268. cation Ltd.1992;502-10. e time ofembryo transfer andothergynecological l forinvitrofertilization 141

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