Cough, Hoarseness, and a History of Amenorrhea: A Delayed Diagnosis of Mycobacterium tuberculosi

Abstract

INTRODUCTION: Tuberculosis (TB) remains a major public health concern worldwide. There has been a global resurgence in the disease with the onset of the acquired immunodeficiency syndrome (AIDS) epidemic. In the United States (U.S.), the availability of anti-retroviral treatment, in addition to improved public health efforts and infection control measures, has contributed to a decline in incidence of the disease, and the majority of U.S. cases now occur in foreign-born individuals from endemic countries. Disease patterns have also changed, with a higher incidence of disseminated and extrapulmonary disease being reported. Sites of extrapulmonary infection commonly include lymph nodes, pleura, bones and joints, but can involve any organ system. The prevalence of genito-urinary tuberculosis varies by country, but is more common in countries with high rates of TB and is a cause of infertility in young women. CASE PRESENTATION: 27 yo Mexican woman with PMH of amenorrhea presented with two months of chronic dry cough and sore throat with voice hoarseness. She denied fevers, night sweats or hemoptysis. She had no known sick contacts, was a non-smoker and had immigrated to the U.S. ten year prior. Physical exam was remarkable for clear lungs and a hoarse voice. Basic labs were within normal limits and an HIV test was negative. Chest X-ray revealed bilateral apical infiltrates; sputum was smear negative for acid fast bacilli (AFB) and a culture was sent. Investigation into her medical history revealed initial presentation two years prior for amenorrhea and intermittent pelvic pain; she reported no pulmonary symptoms at that time. She had a complicated and extensive gynecological workup including pelvic sonogram, exploratory laparoscopy for severe endometriosis and frozen pelvis, and colposcopy with cervical biopsy. The biopsy showed necrotizing granulomas but stains for AFB were negative; no cultures were sent. She was given hormonal challenges with oral contraceptives without improvement. She had a hysterosalpingogram with bilateral tubal occlusion and ultimately underwent a repeat cervical biopsy, only weeks prior to her current presentation. The second biopsy again showed necrotizing granulomas and was smear negative for AFB but the culture was positive for mycobacterium tuberculosis (MTB). Her sputum culture also quickly returned as positive for MTB and the organism was pan-sensitive. She had a fiberoptic examination of her vocal cords with left cord erythema but without defined lesions. She was started on multi-drug treatment with directly-observed therapy for pulmonary, laryngeal and endometrial tuberculosis. DISCUSSION: Genito-urinary TB should be included in the differential of secondary amenorrhea in women from endemic areas. The clinical presentation can be subtle with infertility often the presenting complaint, but patients may also have pelvic pain and menstrual irregularities. Systemic symptoms are rare. Hematogenous dissemination of a primary pulmonary focus to the fallopian tubes, causing salpingitis, constitutes the underlying mechanism. Tubal and endometrial scarring are well-recognized sequelae and can incur major effects on fertility, highlighting the importance of recognizing the disease and treating early. Response to chemotherapy is excellent for all forms of genital tuberculosis however surgery in women is necessary for large tubo-ovarian abscesses. CONCLUSIONS: TB remains a disease with high global burden and can affect multiple organ systems. In patients without the classic respiratory complaints, a high index of suspicion and knowledge of atypical disease presentation, including genito-urinary symptoms, is imperative for timely diagnosis and treatment.