Periabortal Abdominal Tuberculosis

Author Information

Patel Amit, Qureshi Shabnam, Gupta AS.
(*Second Year Resident, ** Assistant Professor, *** Professor. Department of Obstetrics and Gynecology, Seth GS Medical College and KEM Hospital, Mumbai, India.)

Abstract

Pregnancy is an immunosuppressive state in which the immunity of the patient, especially the cell mediated immunity is suppressed to allow implantation and development of the zygote.
With termination of pregnancy, there is a flare up of quiescent infection so that it becomes
symptomatic. We present a case of a postabortal patient who presented with fever and abdominal pain after check curettage done for incomplete abortion. She was suspected to have postabortal sepsis, flare up of pelvic inflammatory disease or genital tuberculosis. CT scan report clinched the diagnosis of abdominal tuberculosis.

Introduction

15-20% of extra pulmonary tuberculosis is genital tuberculosis.[1] Though not very common genital tuberculosis can initially present after obstetric procedures like check curettage for
in complete abortion or in the puerperium. The patient mostly comes with fever and pain in abdomen. Differentiating between postabortal/puerperal sepsis, flare up of pelvic inflammatory disease or genital/abdominal tuberculosis is challenging.

Case report

A 24 year old patient gravida 3, para 1 and 2 abortions presented with complaints of abdominal pain and progressive abdominal distention. It was precipitated after a curettage was performed in a private set up for incomplete first trimester spontaneous abortion. Patient developed low grade fever and abdominal pain on the second post operative day. There was no history of vaginal discharge or burning micturition. Patient consulted multiple private consultants prior to coming to us. She underwent multiple investigations and received broad spectrum antibiotics but had no clinical improvement. On admission she had abdominal pain and vomiting. She was afebrile. She had no foul smelling vaginal discharge, urinary complaints. There was no history of cough or previous tuberculous infection in her or in her family. General examination parameters were normal. Her abdomen was mildly distended and it felt doughy on palpation. Mild tenderness was elicited in the right iliac fossa. On speculum examination cervical os was closed. No bleeding was seen. Cervix and vagina appeared healthy. On bimanual vaginal examination the uterus was normal in size, bilateral fornices were free and no cervical motion tenderness could be elicited.
The results of her investigations are tabulated in the table below. On admission with us the patient had the reports that are shown in the 1st 5 columns of the investigation chart. 

Investigations Chart


2-4-14
3-4-14
8-4-14
11-4-13
17-4-14
21-4-14
Haemoglobin g%
12.3
12.6
12.7
12
10.3
9.0
Total WBC count/mm3
9700
12000
12600
11800
10200
14000
Platelet count lac/mm3
2.53
Adequate
3.10 lac
3.51
Adequate
4.52
ESR


2 mm at 1hr



HIV
negative





VDRL
negative





HbsAg
negative




negative
Leptospirosis
negative




negative
Dengue
negative




negative
PS for Malarial parasite
negative




negative
Malarial antigen test
negative




negative
Widal
negative





Urine routine
WNL

WNL

WNL
WNL
Urine culture


No growth



Blood culture


No growth



Tb Gold


Negative



Ultrasonography (USG) Abdomen and pelvis  It showed a mild bulky uterus, mild fluid in POD and minimal ascites.
CT scan of the abdomen and the pelvis showed locculated ascites and thickening of the peritoneum, multiple mesenteric lymph nodes with extensive stranding, and omental calcification. These features were suggestive of peritoneal Koch’s with mesenteric adenopathy.


Figure 1: CT scan shows the enlarged multiple mesenteric lymph nodes (N).


Figure 2: CT scan shows the locculated ascites (A) and extensive mesenteric stranding (M)

CT scan was suggestive of abdominal Koch’s. The patient was referred to a gastroenterologist who started her on category-2 AKT. She is following up with the gastroenterologist and her symptoms have reduced. 

Discussion

Pregnancy is an immunosuppressive state. This facilitates embryonic implantation. At the end of pregnancy rapid reversal of this immunosuppressive state occurs. This is due to reactivation of the pre-inflammatory substances. This immunocompetent state allows rapid flaring up of those diseases that are dependent on the immune system. Tuberculosis is one of them. The main pathology in tuberculosis is cell mediated immunity against the tubercular antigen, that is suppressed during pregnancy. So as soon as pregnancy is completed latent infection activates and produce symptoms. Lymphocyte activity reactivates within 24 hours and recovers completely within 4 weeks. In previous trials it is seen that tuberculosis becomes symptomatic within 10 days in 76% of cases.[2] In our case activation occurred on day 2 after abortion. The quiescent mycobacterium tuberculosis infection flared up and the patient became symptomatic immediately. As the patient had an early (1st trimester) pregnancy loss, probably her cell mediated immunity suppression reverted back faster.

Conclusion

This case is presented, as tuberculosis is a very important ailment. The clinician has to be alert to its flare up in the immediate peripartum state as delay in diagnosis increases patient morbidity and unnecessary use of empirical antibiotics.

References

1.      Rajamaheshwari N . Pelvic tuberculosis. Available from: http://www.sunmed.org/pelvictb.html
2.      Cheng VC, Woo PC, Lau SK, Cheung CH, Yung RW, Yam LY, et al. Peripartum tuberculosis as a form of immunorestitution disease. Eur J Clin Microbiol Infect Dis 2003;22(5):313-7.

Citation

Patel A, Qureshi S, Gupta AS. Periabortal Abdominal Tuberculosis. JPGO 2014 Volume 1 Number 7 Available from: http://www.jpgo.org/2014/07/periabortal-abdominal-tuberculosis.html