International Journal of

Introduction
 
TUberculosis (TB) is regarded as the chronic disease with low grade symptomatology and few specific complaints in the world. Since the beginning of the 20^th century, the incidence of TB generally and genital TB specially has been steadily decreased in developed countries. But genital TB remains a major health problem in many developing countries, and is responsible for infertility in women HSG is one of the initial diagnostic procedures in the assessment of tubal and peritoneal factors leading to infertility (1-5).
A review of the literature reveals that the highest incidence of TB is still in India (1). The real incidence of pelvic tuberculosis in Iran is still unknown. Several studies depicted TB is more common in patients at reproductive age (3, 6, 7). The actual incidence of genital TB cannot be determined accurately because there are no constant clinical signs and majority of them is discovered incidentally through infertility treatment. According to geographic location, socioeconomic and public health conditions, TB incidence is vary. There is direct relationship between prevalence of genital tuberculosis and pulmonary tuberculosis (1, 8-10). Probable symptoms with genital TB are infertility (most common clinical symptom), pelvic pain, abnormal vaginal bleeding, amenorrhea, vaginal discharge and post-menopausal bleeding (11-15). In some cases the disease presents with an abdominal mass or ascites and simulates an ovarian carcinoma.
Peritoneal tuberculosis which is a form of abdominal tubercolosis, present in three forms: wet type with ascites, dry type with adhesions, and fibrotic type with omental thickening and loculated ascites (3). Sonographic features of wet tuberculosis (with ascites) include ascites, loculated fluid, thickened peritoneum, thickened omentum, endometrial involvement and adnexal masses (3, 4). Dry tuberculosis without ascites show endometrial involvements, adnexal masses, loculated fluid and adhesion (3).
This case series depict the HSG appearances and pathology produced by tuberculosis. TB of the uterus is usually a silent infection with no apparent symptoms as the bacteria may remain latent in your system


Figure 1. Case1: Uterine cavity with normal shape and size. Also there is rigid pipe stem appearance of the fallopian tubes




Figure 2. Case 2: Irregular uterine cavity and clover leaf appearance. Irregular border and beaded appearance in both fallopian tubes




Figure 3 (A, B, C). Case 3. A) HSG 4 years ago, bilateral tubal obstruction with golf-club appearance, B) Recent HSG revealed T shaped uterus, Venous and lymphatic intravasation. C) Uterine ultrasound, tiny foci of calcification within the endometrium which shows some degree of adhesion.



Figure 4. Case 4: Small uterine cavity and linear streaks of calcification in the course of the fallopian tube (Tubal calcification).



Figure 5. Occulsion in both distal isthmic region of fallopian tubes with pipe stem appearance.
 


Figure 6. Small uterine cavity with irregular contour and resembling septate appearance. Diverticular outpouching around ampula in both fallopian tubes which make tuffed appearance.



Figure 7. Normal shape of uterine cavity, irregular contour and diverticular outpouching which surround isthmus of right fallopian tube and make SIN appearance.



Figure 8. Small size of uterine cavity with irregular contour and septate appearance. Obstruction in distal isthmic portion of both tubes and golf club appearance.



Figure 9. Complete obstruction of uterine cavity with glove’s finger appearance. Pelvic calcification (probably lymph node calcification) is detected.


Discussion
 
Tuberculosis (TB) remains the most common worldwide cause of mortality from infectious diseases (15). Genital tuberculosis with its variable presentation is a challenging problem for the gynecologist (11). About 20% of patients with genital TB give a family history of TB (as in case 3 and case 4). Hassoun et al in a 10-year study reported that 1.8% of all tuberculosis cases may have a genito-urinary site (1, 15). Abdominopelvic and peritoneal tuberculosis are not common. Peritoneal tuberculosis and tubo-ovarian lesions have usually minimal findings at CT and frequently misdiagnosed with peritoneal carcinomatosis. MRI is useful for the diagnosis of tubo-ovarian lesions. These lesions presented as no dularities along tubo-ovarian surface.
However they are nonspecific and could be seen in peritoneal seeding by malignant tumors. Although regular pattern of small nodularities along the peritoneum at MRI are helpful findings which are proposed tuberculous peritonitis (14, 16). About 75% of cases with active genital tuberculosis have a normal chest X-ray, so a normal chest X-ray cannot exclude the diagnosis of genital tuberculosis (For instance case4 had normal chest X-ray but had infertility due to genital TB) (10). Tubal tuberculosis spreads to the endometrium in approximately one half of the cases; therefore a negative culture from uterine curetting does not exclude the diagnosis of genital tuberculosis (4).
The fallopian tube is affected in almost all patients with active genital tuberculosis (15, 17, 18). The endometrium is involved in 50 % of all patients, the ovary in 20% of cases and the cervix in 5% of patients (17). In spite of significant technological advances in imaging noted with the advent of ultrasonography, CT and MRI; hystrosalpingography remains the gold standard in evaluating the internal architecture of the female genital tract and fallopian tubes. Also it is the most helpful procedure in suggesting the diagnosis of genital tract TB in patients investigated for infertility.
Tubal lesions in tuberculosis have various appearances in HSG. These features vary from non-specific changes such as hydrosalpinx and strictures to specific patterns such as "beaded tube", (case 2) "golf club tube", (case 3) "pipe stem tube" (case 1), "cobble stone tube" and the "leopard skin tube" (4). Tubal calcification can take the form of linear streaks, which lie in the course of the fallopian tube or appear as faint or dense tiny nodules (as depict in case 4) (5). Calcification of the fallopian tubes or ovaries must be differentiated from calcified pelvic nodes, calcified uterine myomas, pelvic phleboliths and calcification in an ovarian dermoid (5).
Tubal occlusion is the most common HSG finding appeared in genital tuberculosis, which occurs most commonly in the region of isthmus and ampulla (1, 5). We noticed tubal occlusion in all cases (4, 19). Multiple constrictions along the course of the fallopian tube produce beaded appearance (Figure 2). Wide spectrum of occlusion and scars make rigidity in tubes and gives it a pipe stem appearance (Figure 5).
Healing produce densed tissue with scar around tubes which decrease tubes motility and makes them fixed so pritubal adhesion in HSG is revealed. Caseous ulceration of the mucosa of the tube make an irregular contour and diverticular outpouching which may surround the ampulla (tufted appearance) (Figure 6) or the isthmus (SIN view) (Figure 7) (5). The uterine changes in tuberculosis could be categorized as non-specific changes like evidence of endometritis, intrauterine adhesions, asymmetric uterine cavity and specific appearances such as collar-stud abscess, the tuberculosis T-shaped uterus (like in case3) and the pseudounicornuate uterus (4, 5, 15, 19). TB may confuse with other pathologies which may mimic non-specific features of uterine changes (4, 18, 19).
Uterine changes vary from mild and normal view to irregular wall, deformity, asymmetry and obliteration in uterine cavity. TB’s scar cause triangular uterine cavity and make T-shape or septate appearance (Figure 8). Unilateral obliteration followed by unilateral scar in uterine cavity and revealed pseudo unicornuate appearance. Netter Syndrome is a severe degeneration and fibrosis with complete obstruction of uterine cavity. HSG shows glove’s finger appearance that only cervical canal and small portion of uterine cavity may be detected (Figure 9).
Due to progressive endometrial lesion contrast medium may passed through lymphatic and venous systems (Figure 3B). Finally lymph node calcification, tubal and uterine cavity changes in HSG are so helpful in diagnosis. However, some of them are not specific. The diagnostic criteria established by Klein et al are very useful for TB diagnosis and described as follow (20):

1. There is calcified lymph node or irregular calcifications in adnexal area.
2. Obstruction of the fallopian tube in the zone of transition between the isthmus and ampulla.
3. Multiple constrictions along the course of the fallopian tube.
4. Endometrial adhesions and/or deformity or obliteration of the endometrial cavity in the absence of a history of curettage or abortion could be detected.

TB should always be considered in the differential diagnosis of a patient with an abdominal/ pelvic mass and ascites. Imaging findings can be misleading and diagnosis of abdominopelvic TB requires different clinical and laboratory evaluation (21). HSG is a good and simple imaging technique and can identify the lesions in more than 70% of cases (10).