Q: My 33 years old wife has tested positive for tuberculosis (TB) by PCR for which an endometrial aspiration biopsy was done. The doctor has recommended AKT-4 and Pyridoxin (40 mg) medicines for six months. What are the precautions she needs to take while on medication? Is tuberculosis curable? Is it safe to have sex while she is on treatment? Please suggest a diet plan. Does TB infection spread from person to person? What tests should be done to monitor the effects of medication?

A:Tuberculosis of the genito-urinary tract, such as, endometrial TB or tuberculosis endometritis is a form of extra-pulmonary tuberculosis (TB), which occurs generally due to the spread of the bacterium Mycobacterium tuberculosis from a primary focus in the lungs. The disease may manifest as pain, abnormal menstruation, sub-fertility or infertility, along with some other general or constitutional symptoms of TB such as fever, cough, night sweats and weight loss. The specific diagnosis of the disease is achieved by endometrial biopsy, or demonstration of acid-fast bacilli (AFB) either through direct smear of endometrial samples, or after growing them through mycobacterial culture. PCR (polymerase chain reaction) is a relatively new method for the diagnosis of TB. Although it is a highly sensitive technique capable of detecting minute quantities of microbial nucleic acids, because of its extreme sensitivity, it is also susceptible to laboratory contamination. Because of these reasons PCR for any diseases is best done at quality assured laboratories. Detection of AFB on microscopy or concurrent culture positivity helps to corroborate the diagnosis. However, in many instances AFB and culture results may be negative due to low sensitivity of these techniques. In these situations the clinician may take a decision based on history, clinical examination, other laboratory markers.

The infection is curable in majority of the patients if treatment is taken properly, and there are no or few complicating or co-morbid factors (co-existing diseases). (All cases of TB should be considered for an HIV test). Being a form of extra-pulmonary tuberculosis the disease is much less infectious to other members of the household or health care providers. Even with a co-existing pulmonary TB, the sputum is generally rendered non-infectious by 2 weeks of initiation of appropriate therapy. The precautions may include making sure that the anti-tuberculosis therapy (ATT) is taken properly. Failure to comply or adhere to ATT may lead to the development of MDR-TB or multi-drug resistant TB. Pregnancy is possible after an episode of endometrial TB, however, the extent of damage caused by TB of the endometrium and the adjoining structures of the uterus, such as the tubes and ovary, are important. Therefore, ectopic pregnancy and spontaneous abortion can occur.

In some cases although the infection may be cured, inflammatory fibrosis, which accompanies the disease, may cause significant changes to adjoining anatomical structures making it difficult sometimes for successful pregnancy to occur. Sexual transmission of TB is a relatively rare incident but has been reported in medical literature. The chances of transmission are further reduced if the patient is on appropriate treatment (for at least 2 weeks), and the other partner is having good immunity against TB (either due to a previous BCG vaccination, or because of naturally acquired immunity which could be elicited through a tuberculin test). If sexual transmission of TB occurs, the disease may affect the reproductive organs (penis, seminal vesicles, epididymis, testes, prostate) and lead to reproductive problems later. All the 4 first line anti-tuberculosis medications (isoniazid, rifampicin, ethambutol, and pyrazinamide) are generally safe during pregnancy. Streptomycin should be avoided because of the chance of foetal oto-toxicity (leading to hearing impairment). If streptomycin has to be used, the reproductive age group couples may opt for contraceptive measures during that period of treatment. Patients with TB are advised to take a balanced diet containing not only adequate calories but also other essential nutrients such as vitamins and minerals, and water. The pyridoxine, given along with ATT is to prevent certain side effects of ATT (such as peripheral neuropathy due to isoniazid). Rifampicin, which is one of the important medicines of ATT, can lead to reddish discolouration of body fluids (urine, tears, etc). It is important to remember this, lest unnecessary concerns are developed.

The treatment of TB must be monitored by qualified health professionals. This monitoring may include clinical examination whenever required, as well as laboratory tests (such as full blood count, liver function tests, ESR/CRP), or imaging investigations (ultra-sonography, MRI, etc.). A “test of cure” is not available for TB. This also depends how is “cure” defined. The clinician generally describes a patient to be cured (after the full period of treatment is over) based on a number of factors (clinical, laboratory, imaging studies). Last but not least the long-term outcome - such as absence of complications or a successful pregnancy is equally important endpoints for a successful treatment.