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ORIGINAL ARTICLE
Year : 2016  |  Volume : 3  |  Issue : 3  |  Page : 98-103

Sharma's dried tree branch fallopian tubes sign: A new laparoscopic sign in female genital tuberculosis with infertility


Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication21-Apr-2017

Correspondence Address:
Jai Bhagwan Sharma
Room No 3082, III Floor, Teaching Block, Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2348-2907.204665

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  Abstract 


Background: Female genital tuberculosis (FGTB) involves fallopian tubes in 95%–100% cases causing various tubal abnormalities. Objective: To evaluate the laparoscopic findings in FGTB with special reference to a new dried tree branch fallopian tubes sign. Materials and Methods: A total of eighty cases of FGTB diagnosed by demonstration of acid-fast bacilli on microscopy or culture on endometrial or peritoneal biopsy or positive endometrial or peritoneal biopsy or demonstration of epithelioid granuloma on biopsy or positive polymerase chain reaction to Mycobacterium tuberculosis on endometrial biopsy with findings of FGTB on laparoscopy or hysteroscopy were included in this prospective study. Diagnostic laparoscopy was performed in all cases. Results: Definite findings of FGTB such as caseous nodules, tubercles, beaded tubes were seen in 33 (41.2%) cases while probable findings of FGTB such as congested and hyperemic fallopian tubes, hydrosalpinx obstructed tubes, pelvic adhesions, and straw-colored fluid were observed in rest 47 (58.8%) cases. A new dried tree branch fallopian tubes sign was seen in 7 (8.0%) cases being bilateral in 4 (5%) and unilateral in 3 (3.7%) cases. Conclusion: The new sign Sharma's dried tree branch fallopian tubes sign appears to be a useful sign in FGTB. However, larger prospective studies are needed before its routine recommendation in clinical practice.

Keywords: Caseous nodules, dried tree branch fallopian tubes sign, fallopian tubes, female genital tuberculosis, hydrosalpinx


How to cite this article:
Sharma JB. Sharma's dried tree branch fallopian tubes sign: A new laparoscopic sign in female genital tuberculosis with infertility. IVF Lite 2016;3:98-103

How to cite this URL:
Sharma JB. Sharma's dried tree branch fallopian tubes sign: A new laparoscopic sign in female genital tuberculosis with infertility. IVF Lite [serial online] 2016 [cited 2017 Sep 20];3:98-103. Available from: http://www.ivflite.org/text.asp?2016/3/3/98/204665




  Introduction Top


As per the World Health Organization (WHO) report 2016, of 9 million tuberculosis (TB) cases annually globally, 3.2 million cases occur in women with 480,000 deaths.[1] The WHO has recommended directly observed treatment short course (DOTS) strategy management of TB, and the same has been implemented by the Revised National TB Control Program (RNTCP) of Government of India for both pulmonary and extrapulmonary TB (EPTB) with almost 86% cure rate.[2],[3]

Female genital TB (FGTB) is an important variety of EPTB and is an important cause of significant morbidity and short and long-term sequelae such as infertility, chronic pelvic pain, tubo-ovarian masses, and menstrual dysfunction in infected women, especially in developing countries like India.[4],[5],[6],[7],[8],[9],[10]

There can be dilemma in diagnosis of FGTB due to paucibacillary nature of the disease. The gold standard diagnostic methods include detection of acid-fast bacilli (AFB) on microscopy or culture on endometrial or peritoneal biopsy or demonstration of epithelioid granuloma on histopathology of endometrial or peritoneal biopsy.[11],[12] However, they are positive in some cases only due to paucibacillary nature of disease.[4],[11],[12]

Polymerase chain reaction (PCR) is highly sensitive but has high false positivity and alone should not be used to make diagnosis of FGTB.[13],[14]

Gene Xpert is a newer diagnostic modality with nearly 100% specificity but lower (30%–40%) sensitivity.[15]

Imaging modalities such as hysterosalpingography, ultrasound, computed tomography (CT) scan, magnetic resonance imaging (MRI), and positron emission tomography (PET) are mainly useful for tubercular tubo-ovarian masses but may give conflicting reports.[16],[17],[18]

Endoscopic visualization by (both laparoscopy and hysteroscopy) has been used successfully for diagnosis of FGTB.[19],[20] Laparoscopy and dye test is the most reliable test to diagnose FGTB, especially tubal, ovarian, and peritoneal disease in both pelvic and abdominopelvic TB.[19] Various laparoscopic findings include caseous nodules, tubercles, hyperemic and congested tubes, pelvic and abdominal adhesions, hydrosalpinx, pyosalpinx, and straw-colored fluid in pouch of Douglas.[19],[21] Fallopian Tubes often become dilated (hydrosalpinx), may have pus (pyosalpinx), or may become rigid in FGTB. We present our findings on new laparoscopic sign of dried tree branch fallopian tubes sign in FGTB in which tubes look rigid-like branches of a dried tree.


  Materials and Methods Top


A total of eighty cases with diagnosis of FGTB on detection of AFB on microscopy or culture, on endometrial aspirate or peritoneal biopsy or demonstration of epithelioid granuloma on endometrial or peritoneal biopsy and or laparoscopic findings of FGTB were taken in this prospective study. The study was part of our large TB project which was ethically cleared from the Institute Ethics Committee. The study was conducted between June 2011 and June 2016 at a tertiary referral center in Northern India.

Informed written consent was taken from all the study participants. All patients underwent a detailed clinical and laboratory evaluation for FGTB. Diagnostic laparoscopy with or without hysteroscopy was performed in all patients. Careful inspection of whole abdominal cavity was made by rotating the laparoscope by 360° in the abdomen for any tubercular lesions and abdominal and pelvic adhesions. All tuberculous lesions such as tubercles, caseous nodules, shaggy areas, nodular or patchy salpingitis, hydrosalpinx, pyosalpinx, beading of tubes, hyperemia and congestion of tubes and patency of tubes and looks of tubes were carefully observed and findings were carefully recorded. After confirmation of diagnosis of FGTB, all women were given Category I antitubercular therapy (ATT) under RNTCP of India under DOTS strategy using isoniazid, rifampicin, pyrazinamide and ethambutol thrice a week for 2 months (intensive phase) followed by rifampicin and isoniazid thrice a week for 4 months (continuation phase). All women were followed up every 2 months for liver function tests and any adverse effects.

Statistical analysis

Descriptive statistics such as mean, median, standard deviation, and range values were calculated for study characteristics such as age, body mass index (BMI), and duration of infertility. Continuous variables were tested for normality assumptions using Kolmogorov–Smirnov tests. Chi-square test or Fisher's exact test was used for frequencies of categorical variables. A two-tailed probability level P< 0.05 was considered for statistical significance. All data analyses were carried out using IBM SPSS statistics for windows, version 19.0. Armonk, New York, IBM Corp.


  Results Top


Characteristics of the patients and disease at baseline are shown in [Table 1]. Thus, age ranged between 20 and 45 years with mean being 28.5 ± 3.25 years. The mean parity was 0.6 while the mean BMI was 22.3 ± 2.15 kg/m 2. Infertility was seen in all 80 (100%) cases with primary infertility in 62 (77.5%) and secondary infertility being in 18 (22.5%) cases. The mean duration of infertility was 4.2 years. Various menstrual characteristics are also shown in [Table 1]. Normal menstrual cycles were seen in 22 (27.5%) cases, hypomenorrhea in 25 (31.2%) cases, oligomenorrhea in 26 (32.5%) cases, primary amenorrhea in 2 (2.5%), secondary amenorrhea in 10 (12.5%) cases while menorrhagia was seen in 3 (3.75%) women.
Table 1: Characteristics of women with symptoms and signs (n=80)

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Fever, weight loss, and anorexia were seen in 18 (22.5%), 29 (36.2%) and 31 (38.7%) women, respectively. Abdominal pain was observed in 5 (6.25%) women, chronic pelvic pain in 33 (41.2%) cases, abdominal mass in 6 (7.5%), pelvic or adnexal mass in 30 (37.5%) cases with some women having more than one symptom. Diagnosis of FGTB was made as per findings in [Table 2] with some women having more than one finding. Positive AFB on microscopy of endometrial aspirate was seen in 10 (12.5%) cases, culture of AFB on endometrial aspirate was positive in 11 (13.7%) cases, positive AFB on microscopy or culture of peritoneal biopsies in 7 (8.7%) cases, epithelioid granuloma on endometrial biopsy in 23 (28.7%) cases, or peritoneal and caseous nodule biopsy in 18 (22.5%) cases. Positive PCR on endometrial or peritoneal fluid was seen in 76 (95%) cases. Hysterosalpingography (HSG) was not routinely performed in FGTB cases due to risk of flare up of disease. However, in some cases of unsuspected FGTB, HSG had already been done from outside. It showed marked narrowing of uterine cavity with appearance of rigid dried tree branch in both fallopian tubes with no spill (blocked tubes) [Figure 1].
Table 2: Diagnosis of female genital tuberculosis (n=80)

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Figure 1: Hysterosalpingography showing dried tree branch sign in both fallopian tubes in a case of female genital tuberculosis

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Definite findings of FGTB on laparoscopy were seen in 33 (41.2%) cases while probable findings of FGTB on laparoscopy were seen in 47 (58.8%) cases.

Various diagnostic laparoscopic findings in FGTB cases are shown in [Table 3]. Tubercles were observed on fallopian tubes, ovaries, uterus, pouch of Douglas, or pelvic peritoneum in 33 (41.2%) cases. Hydrosalpinx was observed in 19 (23.7%) cases, pyosalpinx in 4 (5%) cases, beaded tubes in 7 (8.7%) cases, shaggy area on uterus, fallopian tubes, or pelvic peritoneum were observed in 32 (40%) cases, congested and hyperemic tubes in 33 (41.2%) cases, caseous nodules on fallopian tubes, pelvic peritoneum [Figure 2], or pouch of Douglas in 26 (32.5%) cases, encysted ascites in 13 (16.2%) cases, abdominal adhesions in 28 (35%) cases and pelvic adhesions in 33 (41.2%) cases. Fallopian tubes were rigid dried tree branch like with no distension on introduction of dye (Sharma's) dried tree branch sign in 7 (8.7%) cases which was bilateral in 4 (5%) [Figure 3] and unilateral in 3 (3.7%) cases [Figure 4].
Table 3: Laparoscopic fi ndings in female genital tuberculosis (n=80)

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Figure 2: Laparoscopy showing caseous nodules on peritoneum

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Figure 3: Laparoscopy showing bilateral dried tree branch sign in both fallopian tubes in female genital tuberculosis

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Figure 4: Laparoscopy showing dried tree branch sign in left fallopian tube (arrow) and hydrosalpinx in right fallopian tube (double arrow)

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Due to chronic tuberculous infection of fallopian tubes and cornual blockage, the tube becomes hard, nonpliable, nondistensible and nonelastic like the branch of dried tree (dried tree branch sign). It does not take any dye due to cornual blockage. The overall incidence of dried tree fallopian tubes sign was 8.7% being bilateral in 5% cases and unilateral in 3.7% cases.

Diagnostic laparoscopy in FGTB is hazardous and difficult as shown in [Table 4]. Difficulty in pneumoperitoneum was observed in 19 (23.7%) cases, difficulty in insertion of trocar and cannula was seen in 11 (13.7%) cases, difficulty in visualization of pelvic organs due to adhesions was seen in 13 (16.2%) cases, excessive bleeding was seen in 7 (8.7%) cases, subacute intestinal obstruction was observed in 7 (8.7%) cases, while flare up of tuberculosis was seen in 4 (5.0%) cases. Excessive bleeding was managed by cauterization of bleeder. Subacute intestinal obstruction and flare up of TB cases were managed by keeping the patients admitted for 2–3 days in hospital and were all controlled on conservative treatment. None of the patients needed laparotomy.
Table 4: Diffi culties and complications encountered at laparoscopy in female genital tuberculosis (n=80)

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The various complications of ATT are shown in [Table 5]. The compliance rate was 100% with four women needing readjustment of ATT due to derangement of liver function tests but all women completed ATT. The treatment was given under supervision with DOTS with responsibility of treatment being on DOTS provider.
Table 5: Complications of anti-tuberculous therapy (n=80)

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  Discussion Top


FGTB is a common disease in developing countries causing significant morbidity and short- and long-term sequelae, especially infertility.[4],[5],[6],[7],[8],[22] Fallopian tubes are involved in 90%–100% cases, uterus in 50%–80% cases, ovaries in 20–30 cases, cervix in 5–15% cases, vagina and vulva in 1% cases.[4],[22] Involvement of fallopian tubes is usually bilateral. Various types of TB salpingitis are TB endosalpingitis, exosalpingitis, interstitial TB salpingitis, and salpingitis isthmica nodosa.[4],[22] In TB endosalpingitis, the infection starts from endosalpinx and is usually through hematogenous route of spread with thickening, enlargement and tortuosity of fallopian tubes. Sometimes unilateral or bilateral pyosalpinx may be formed due to caseation in tubal wall with blockage of both ends of fallopian tubes due to fibrosis. Endosalpinx may be edematous, hyperplastic, or may be totally destroyed.[4],[22]

In tuberculous exosalpingitis, disease starts at muscularis mucosa of fallopian tubes with congestion of tubes. Later, there occur beaded tubes with calcifications and tubal blockage, tubo-ovarian masses, hydrosalpinx, pyosalpinx, and massive adhesions formation.[4],[22]

Diagnosis of FGTB is made by demonstrating AFB on microscopy and culture on endometrial or peritoneal biopsy or histopathological demonstration of epithelioid granuloma on endometrial or peritoneal biopsy, but diagnosis may be missed due to paucibacillary nature of disease.[4],[11],[12],[22] PCR is highly sensitive but may be false positive and alone is not diagnostic of FGTB.[13],[14] Imaging modalities (HSG, ultrasound, CT scan, MRI, and PET) are useful in only TB tubo-ovarian masses but are not diagnostic of TB.[16],[17],[18]

Diagnostic hysteroscopy and laparoscopy are very useful in diagnosis of FGTB by demonstration of tubercles, caseous nodules, and adhesions.[19],[20],[21] Laparoscopy and dye test remains the mainstay of diagnosis in FGTB and may show definite findings of FGTB (tubercles, caseous nodules, and beaded tubes) or probable findings of FGTB (congested tubes, hydrosalpinx, obstructed lumen, pelvic and abdominal adhesions, and encysted ascites). In the present study, definite findings of FGTB were seen in 33 (41.2%) cases, while probable findings were seen in 47 (58.8%) cases. In our previous studies on FGTB, we observed hanging gall bladder and ascending colonic adhesions in cases of abdomino pelvic TB.[23],[24]

We also observed blue python sign in fallopian tubes on laparoscopy and dye test in FGTB cases with alternate dilation and constriction of fallopian tubes resembling blue python [25] due to damage of fallopian tube by TB with partial blockage. We also observed Sharma's kissing fallopian tubes sign in a case of FGTB with fusion of fimbrial ends of both fallopian tubes due to caseous material.[26]

We observed dried tree branch sign in 7 (8.7%) in FGTB (bilateral in 5%, unilateral in 3.7%) cases in which the fallopian tubes are rigid pipes with no uptake of dye due to tubal blockade and fibrosis resembling branchs of a dried tree.


  Conclusion Top


The new sign Sharma's dried tree branch fallopian tubes sign appears to be a useful sign in FGTB. However, larger prospective studies are needed before its routine recommendation in clinical practice.

Acknowledgment

The author is thankful to Prof. Alka Kriplani, Prof. Sunesh Kumar, Sona, SRF and Pawan for their help.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no confl icts of interest.



 
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Global TB Report 2016, World Health Organisation WHO/HTM/TB 2015. Geneva: WHO; 2015.  Back to cited text no. 1
    
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Dam P, Shirazee HH, Goswami SK, Ghosh S, Ganesh A, Chaudhury K, et al. Role of latent genital tuberculosis in repeated IVF failure in the Indian clinical setting. Gynecol Obstet Invest 2006;61:223-7.  Back to cited text no. 10
    
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Grosset J, Mouton Y. Is PCR a useful tool for the diagnosis of tuberculosis in 1995? Tuber Lung Dis 1995;76:183-4.  Back to cited text no. 14
    
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Sharma JB, Kriplani A, Dharmendra S, Chaubey J, Kumar S, Sharma SK. Role of Gene Xpert in diagnosis of female genital tuberculosis: A preliminary report. Eur J Obstet Gynecol Reprod Biol 2016;207:237-8.  Back to cited text no. 15
    
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Sharma JB, Pushparaj M, Roy KK, Neyaz Z, Gupta N, Jain SK, et al. Hysterosalpingographic findings in infertile women with genital tuberculosis. Int J Gynecol Obstet 2008;101:150-5.  Back to cited text no. 16
    
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Sharma JB, Karmakar D, Hari S, Singh N, Singh SP, Kumar S, et al. Magnetic resonance imaging findings among women with tubercular tubo-ovarian masses. Int J Gynecol Obstet 2011;113:76-80.  Back to cited text no. 17
    
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Sharma JB, Karmakar D, Kumar R, Shamim AS, Kumar S, Singh N, et al. Comparison of PET/CT with other imaging modalities in female genital tuberculosis in a high prevalence, tertiary care setting. Int J Gynecol Obstet 2012;118:123-8.  Back to cited text no. 18
    
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Jindal UN, Bala Y, Sodhi S, Verma S, Jindal S. Female genital tuberculosis: Early diagnosis by laparoscopy and endometrial polymerase chain reaction. Int J Tuberc Lung Dis 2010;14:1629-34.  Back to cited text no. 19
    
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Sharma JB, Roy KK, Pushparaj M, Kumar S. Hysteroscopic findings in women with primary and secondary infertility due to genital tuberculosis. Int J Gynecol Obstet 2009;104:49-52.  Back to cited text no. 20
    
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Volpi E, Calgaro M, Ferrero A, Viganò L. Genital and peritoneal tuberculosis: Potential role of laparoscopy in diagnosis and management. J Am Assoc Gynecol Laparosc 2004;11:269-72.  Back to cited text no. 21
    
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Sharma JB.In vitro fertilization and embryo transfer in female genital tuberculosis. IVF Lite 2015;2:14-25.  Back to cited text no. 22
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Sharma JB. Sharma's hanging gall bladder sign: A new sign for abdominopelvic tuberculosis: An observational study. IVF Lite 2015;2:94-8.  Back to cited text no. 23
  [Full text]  
24.
Sharma JB. Sharma's ascending colonic adhesion: A new sign in abdomino pelvic tuberculosis with infertility. IVF Lite 2016;3:18-22.  Back to cited text no. 24
  [Full text]  
25.
Sharma JB. Sharma's python sign: A new tubal sign in female genital tuberculosis. J Lab Physicians 2016;8:120-2.  Back to cited text no. 25
[PUBMED]  [Full text]  
26.
Sharma JB. Sharma's kissing fallopian tubes sign: A new tubal sign in female genital tuberculosis. J Obstet Gynaecol India. DOI: 10.1007/s13224-016-0944-5. [In press].  Back to cited text no. 26
    

 
  Authors Top


Dr. Jai Bhagwan Sharma MD, PhD, FRCOG, FAMS is working as an Professor in Obstetrics and Gynaecology at All India Institute of Medical Sciences, New Delhi, India. He has 330 publications in Indexed and non-indexed Journals including 115 in peers reviewed indexed international and national Journals. He is the author of “Textbook of Obstetrics” and “Midwifery and Gynecological Nursing” and edited 2 books. He is involved with research projects with OXFORD University, Indian Council of Medical Research and Central TB division and Ministry of Health and Family Welfare Govt. of India. His research areas are Genital Tuberculosis, Anemia in pregnancy and Urogynaecology.


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