African Health Sciences Makerere University Medical School ISSN: 1680-6905 EISSN: 1729-0503 Vol. 7, Num. 1, 2007, pp. 37-37

African Health Sciences, Vol. 7, No. 1, March, 2007, pp. 37

LETTER TO THE EDITOR

Genital tuberculosis presenting as pyrexia of undetermined origin.

Adamu G Bakari¹, Geoffrey C Onyemelukwe¹, Michael A Akolawole¹, Salihu B Muazu¹ and Abdullahi J Randawa²

(Departments of medicine¹ and Obstetrics and Gynaecology²,Ahmadu Bello University Teaching Hospital, Zaria, Nigeria.)

Correspondence Adamu G Bakari Senior Lecturer and consultant Physician, Department of Medicine,A.B.U. Teaching Hospital,Zaria Nigeria. E-mail abgirei@yahoo.com. Phone: +234 8037018639

Code Number: hs07008

Abstract.

A case of Genital tuberculosis in a female patient is presented.The key presenting features in this lady were chronic weight loss, colicky lower abdominal pains, fever, and amenorrhea.
The fact that tuberculosis is still very much around and could present in unpredictable ways is emphasised.

Introduction

Tuberculosis is the commonest chronic infectious disease in the tropics, the tubercle bacillus affects about a third of the world’s population and causes more death worldwide than any other single infectious disease^1-3. Although the respiratory system is the commonest and preferred site for the infection, all systems of the body are susceptible. Its manifestations are also protean depending on which system(s) is /are affected^4-7.We present a case of Genital tuberculosis in a female whose presentation was mainly pyrexia of undetermined origin and amenorrhea.

Case presentation

MU a 40-year-old house wife who had no formal education , was admitted to Ahmadu Bello university teaching hospital, Zaria in August 2002. Her complaints were those of colicky lower abdominal pains for one year, and intermittent fever for 6 months.There was associated history of amenorrhea for six months, and progressive weight loss. She denied any respiratory symptoms or contact with a known case of open pulmonary tuberculosis of a chronically coughing person.

Clinical examination revealed a young chronically wasted lady, with temperature of 38.4 0C and oral candidiasis. The rest of the physical examination was not remarkable. Abdominal and pelvic ultrasound scans were normal.The uterus was normal in size and contours and 3-5 cm in its maximal diameter, adnexae and the pouch of Douglas were normal.

Endometrial biopsy revealed few endometrial glands, extensive tissue necrosis with numerous multinucleated giant cells of the Langerhans type.

She was commenced on directly observed therapy short course (DOTS) comprising INH, Pyrazinamide, Ethambutol and Rifampicin. Serial weights, ESR and general well being continued to improve on this regimen. She resumed normal menstrual periods two months after commencement of anti-tuberculosis therapy.

Discussion

The key presenting features in this lady is a chronic wasting disease with colicky lower abdominal pains, fever, and amenorrhea.There was no change of bowel habits noted or cardiopulmonary symptoms.There are several disease states, which could present just like this. Notable among them are disseminated tuberculosis, chronic fungal infections such as histoplasmosis, HIV infection with the AIDS syndrome, and neoplastic conditions such as non-Hodgkin’s lymphoma among others.

In the pre-AIDS era, genito-urinary tuberculosis accounts for 6% of extra pulmonaryTB⁴. Genital tuberculosis results from haematogenous spread from a primary pulmonary focus or secondary to urinary involvement by tuberculosis of adjacent structures⁶. In this patient the source is most likely from the lungs as urine microscopy did not show evidence of infection. Pelvic pain is the commonest symptom in females with genital tuberculosis. However, 50% of women present due to infertility, and those who present primarily with infertility, rarely have any symptom⁷. Our patient had both pelvic pain and secondary infertility (last confinement was 3 years).The endometrial biopsy evidence of numerous multinucleated giant cells of the Langerhans type and clinical improvement on anti tuberculosis medication which culminated in the resumption of her normal menstrual flow two months after commencement of therapy leaves no doubt as to the diagnosis.The negative mantoux reaction may be due to an overwhelming infection and her poor nutritional status, even then a higher dose of the PPD might have elicited some response.

References.

1. Kochi A.The global tuberculosis situation and the new control strategy of the world Health Organization. Tubercle 1991; 72:1-6.
2. Raviglione MC, Dye C, Schmidt S, Kochi A. Assessment of worldwide tuberculosis control. Lancet 1997; 350:624-629.
3. World Health Organization. Global tuberculosis control: Surveillance, planning, and financing. WHO Report 200 WHO/ CDS/TB/2003.3163. Geneva: WHO, 2003.
4. Gruth AA, Kim U. The reappearance of abdominal tuberculosis. Surg Gynaecol Obstet1991; 172:432-436.
5. Pettengel KE, Pirie D, Sinjee AE. Colonoscopic features of early intestinal tuberculosis. S Afr Med J 1991; 79:279-280.
6. Shaefer G. Female genital tuberculosis. Clin Obstr Gyneacol 1976; 19:223-239.
7. Morris CA, Boxall FN, Caylon HR. Genital tract tuberculosis in subfertile women. J Med Microbiol 1970; 3:85-90.

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