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TUBERCULOSIS OF THE FALLOPIAN TUBES

Various sources on the topic of genital TB appear to agree that the fallopian tubes are likely
the initial source of infection, because both tubes are involved in nearly 100% of cases.5, 25, 43
The fallopian tubes constitute the initial focus of genital TB in the overwhelming majority of
cases (Table 1), and TB has accounted for approximately 5% of all cases of salpingitis in
many areas of the world.44 In more than 90% of patients with genital TB, the tubes are
involved bilaterally. Although only one tube appears infected, there probably are microscopic
lesions in the other. In the early stages, the tubes show little change, but as progression
occurs, the diameter of the tube becomes larger. Usually, the ampullary region shows the
earliest and most extensive changes, the fimbrial processes become greatly swollen, and the
ostia remain open or closed (Fig. 1). The gross appearance varies and is nondiagnostic; the
tubes may appear normal or only slightly edematous but are much more likely to present a
picture consistent with chronic salpingitis of a nontubercular nature.

Table 1. Frequency of tuberculosis in genital organs

Organ Frequency (%)

Fallopian tubes 90100
Endometrium 5060
Ovaries 2030
Cervix 515
Vulva and vagina 1
(From Schaefer G: Female genital tuberculosis. Clin Obstet Gynecol 19:23, 1976)

Fig. 1. An enlarged fallopian tube is seen with a pouting fimbrial end

on the right side of the photograph.

The isthmus and the adjacent interstitial portion of the tube may remain free of TB. As the
process continues, the tubes become softer, and caseation develops in the inner wall. At
times, the peritoneal surfaces of the tubes will be studded with tubercles, and the cross
sections may show them to be filled with caseous material.25 In 2550% of cases of genital
TB, the tubes remain patent with recognizable everted fimbriae, even if the remaining tube is
enlarged and distended, the so-called tobacco-pouch appearance.37, 44
MICROSCOPIC APPEARANCE

Microscopically, granulomata and a chronic inflammatory infiltrate may involve the full
thickness of the tubal wall, and caseation necrosis is common in advanced states. Some
tubercles have a caseous center, which, as they progress, involves the overlying mucous
membrane or causes pressure atrophy. After liquefaction, the caseous foci pour their bacilli
into the lumen and form an ulcer at the site. Caseation or a pyogenic membrane lines the
ulcer; beyond the inner zone is an area of vascular granulation tissue containing epithelioid
and giant cells. Adhesion of the individual foci may occur, resulting in large cystic spaces
pseudofollicular salpingitis. When healing occurs, the picture is further changed, and calcium
deposits, hyalinization, and increased fibrous tissue may be seen. The mucosa frequently
exhibits a hyperplastic, adenomatous pattern with a complex network of fused papillae that
may be confused with adenocarcinoma (Fig. 2) and has been associated with ectopic
pregnancies.37, 44 There is some suggestion that this pattern may actually predispose to the
development of tubal adenocarcinoma, although the evidence is insufficient for statistical
assessment.45 Tuberculous salpingitis may contain Schaumann bodies, which are conchoidal,
laminated, calcified structures surrounded by foreign body giant cells (Fig. 3). In chronic
tuberculous salpingitis, unless multiple sections are taken, the characteristic lesion may be
missed.

Fig. 2. Tuberculous salpingitis. Chronic salpingitis due to

tuberculosis presents the characteristic histologic features of
the tuberculous granuloma: lymphocytes, epithelioid cell
granulomata, and giant cells of both the Langerhans and the
foreign body type are seen. Tuberculous infection of the
fallopian tube often results in an adenomatous
proliferation of the lining epithelium. This is seen on the left
of this photomicrograph and may give rise to confusion with
adenocarcinoma. (100.)
Fig. 3. Tuberculous salpingitis may contain Schaumann
bodies, which are more characteristic of sarcoidosis than
tuberculosis. These are conchoidal, laminated, calcified
structures, usually surrounded by foreign body giant cells.
(100.).

TYPES OF TUBERCULOUS SALPINGITIS

Exudative

In the exudative type, the tube may be significantly enlarged. Although a large pyosalpinx
may form, these tubes show few adhesions and usually are reasonably mobile if surgery is
needed. Frequently, the organs contain a large amount of caseous material plus purulent
exudate from secondary infection. This is a relatively acute phase of the process.

Productive-Adhesive
In the productive-adhesive form, which is found most frequently at laparoscopy or
laparotomy, the tubes are studded with tubercles and are densely adherent to the surrounding
organs. The tubercles are seen mostly near the attachment of the tube to the mesosalpinx. The
tube wall is thickened and nodular, and the fimbriae and tube are slightly swollen.
Eventually, when the process starts healing, it results in calcification and fibrosis.

MODE OF SPREAD FROM TUBES

After the initial involvement of the tubes, the tuberculous infection spreads to the uterus and
ovaries by direct extension. Extension to the uterus is along the endometrium and rarely into
the myometrium. Direct hematogenous spread to the uterus as part of a generalized
hematogenous TB has rarely been reported.

The ovaries may be involved by direct spread from adjacent organs. In most cases, infection
spreads from the tube, and the lesion is seen on the surface of the ovaries. Rarely, the
infection extends from the peritoneum to the ovary. Hematogenous spread usually affects the
center of the ovary, and the periphery appears normal.

The cervix is involved by spread from the endometrium or as part of the hematogenous
infection. Tuberculous infection of the vagina and vulva may follow injury or abrasions to
these structure in the presence of tubercle bacilli from the upper genital tract, intestinal tract,
or lungs.

Dellepiane stated that the use of antituberculous drugs has tended to change the clinical
picture of the disease, resulting in a decreasing incidence of acute forms and an increasing
incidence of subacute and chronic forms.46 On the basis of 965 cases of genital TB in which
the pathogenesis could be defined precisely by a series of clinical, laboratory, radiologic, and
laparoscopic procedures, he described genital TB as primary in 0.2%, hematogenous in origin
in 59.2%, and descending in 40.6%. The latter route is by way of the lymphatics from the
lungs to the intestinal lymph nodes and the tubes.