Annals of Tropical Medicine and Public Health
Home About us Ahead Of Print Instructions Submission Subscribe Advertise Contact e-Alerts Editorial Board Login 
Users Online:3102
  Print this page  Email this page Small font sizeDefault font sizeIncrease font size
 


 
Table of Contents   
CASE REPORT  
Year : 2013  |  Volume : 6  |  Issue : 1  |  Page : 117-119
Pelvic-peritoneal tuberculosis presenting as an adnexal mass and mimicking ovarian cancer


Department of Medicine, Kasturba Medical College, Manipal, Karnataka, India

Click here for correspondence address and email

Date of Web Publication18-Jul-2013
 

   Abstract 

Diagnosis of pelvic- peritoneal tuberculosis is often difficult, because of its nonspecific clinical, laboratory and radiological findings. The presence of an adnexal mass, ascites, and raised CA 125 level, may be mistaken as ovarian malignancy. Peritoneal tuberculosis should be considered in the differential diagnosis of adnexal masses, ascites and elevated CA 125. Ascitic fluid adenosine deaminase (ADA), polymerase chain reaction (PCR) for Mycobacterium tuberculosis and endometrial biopsy may help to distinguish pelvic-peritoneal tuberculosis from ovarian malignancy. Peritoneal tuberculosis can be managed by antituberculosis therapy (ATT), therefore these test should be performed before surgery to exclude peritoneal tuberculosis, so that invasive and expensive surgery could be avoided.

Keywords: CA 125, ovarian malignancy, pelvic- peritoneal tuberculosis

How to cite this article:
Gupta AN, Shivashankara K N. Pelvic-peritoneal tuberculosis presenting as an adnexal mass and mimicking ovarian cancer. Ann Trop Med Public Health 2013;6:117-9

How to cite this URL:
Gupta AN, Shivashankara K N. Pelvic-peritoneal tuberculosis presenting as an adnexal mass and mimicking ovarian cancer. Ann Trop Med Public Health [serial online] 2013 [cited 2019 Dec 15];6:117-9. Available from: http://www.atmph.org/text.asp?2013/6/1/117/115177

   Introduction Top


Diagnosis of extra pulmonary tuberculosis is usually difficult because of varied presentation and lack of sensitive tests. [1],[2] Tuberculosis has been called a great mimic, particularly so in the abdomen, where its manifestation can resemble a variety of diseases. [3] In most cases diagnosis is reasonably made by the process of exclusion. [4] Diagnosis of pelvic- peritoneal tuberculosis is often difficult, because of its nonspecific clinical, laboratory and radiological findings and because of the insensitivity and nonspecificity of the currently used clinical and biochemical tests, diagnosis is usually depended on peritoneal biopsies by laparoscopy or laparotomy. Despite advances in drug therapy and diagnostic facilities, tuberculosis remains a major health problem in the developing countries especially Africa and Indo-Pak subcontinent. [4]


   Case Report Top


A 45-years old multiparousfemale with no premorbid illness came to emergency ward(EW) with complaints of fever, abdomen pain and distention since 6 months. Patient was apparentlynormal 6 monthsback she had lowgrade, intermittentfever more during evening time. Diffuse abdomen pain more in lower abdomen associated with abdomen distention which was gradually worsening, pain which was non-radiating and not associated with any aggravating or relieving factor. Occasionally patient had dry cough, headache, and back pain. Patient also complained of decreased appetite and 12 kg weight loss in 6 months. Patient did not give any history of diabetes mellitus, hypertension, tuberculosis or contact with tuberculosis patient, ischemic heart disease, or bronchial asthma in the past.

On examination in EW, patient was conscious and oriented, afebrile, pallor present, no palpablelymphnodes. Pulse Rate:- 78/bpm, Blood Pressure:- 110/70 mm of Hg, Respiratory Rate:-16/min and spot oxygen saturation (SPO 2 ):-99% on room air.

Per abdomen examination, abdomen distended umbilicus everted on palpation abdomen doughy in consistency, liver palpable 2 cm below the right costal margin with nodular surface, spleen not palpable, shifting dullness waspresent. Pelvic examination revealed normal size, anteverted, mobile uterus. Right adnexa were palpable. Othersystems were normal.

Initial laboratory studies showed hemoglobin (Hb):- 10.3 g/dl, packed cell volume (PCV):-31%, total leukocyte count:-6000cells/mm 3 , neutrophils 56 %, lymphocytes 37 %, monocytes 4%, and esonophils 3 %. Platelet count:-5,00,000 cells/mm 3 , erythrocyte sedimentation rate (ESR):-27mm/h, iron:-17 ug/dl, total iron binding capacity(TIBC):- 254 ug/dl, Ferritin:- 63 ng/ml. Blood sugar, renal function tests, liver function tests electrolytes, and fasting lipid profiles were within normal limits. Two blood cultures from different site were sterile.Mantoux test and three samples of sputum acid- fast bacteria (AFB) were negative. Carcinoembryonicantigen (CEA):- 0.998ng/ml,carbohydrate antigen (CA) 125 – 223.5 U/ml. Chest X-ray, echocardiography and electrocardiography (ECG) were unremarkable. Serology for human immunodeficiency virus (HIV), Hepatitis B and C were negative. Abdominal sonographyrevealed right adnexal mass with ascites, peritoneal and omental deposits. Computed tomography (CT) scan revealed a well-defined solid- cystic lesion in the right adnexa with extensive peritoneal deposits, omental caking, ascites and cardio phrenic lymph nodes, the Imaging features were s/o a right adnexal mass with extensive peritoneal metastases [Figure 1]a-c. Ascites fluid aspirationreports s/o exudative fluid, ADA was 15 U/L and malignant cytology was negative.
Figure 1: (a-c) A well-defined predominantly cystic lesion having a small enhancing solid component along the inferior aspect is seen in the right adnexal region

Click here to view


In view of the history, clinical examination, lab reports and imaging, the diagnosis was made as ovarian malignancy. This case was followed with diagnostic laparoscopy and peritoneal biopsy, biopsy was sent for histopathology examination;its result showed fibro adipose tissue with multiple well-formed and confluent granulomas composed of central caseous necrosis, epithelioid cellsseen, AFB: positive suggestive of tuberculous peritonitis.

The diagnosis was revised to tubercularperitonitis andpatient was put on anti-tubercular drugs Ethambutol, INH, Rifampicin and Pyrazinamide (EHRZ). On follow -up after 1month, patients became symptomatically better and afebrile.


   Discussion Top


Majority of the cases with peritoneal tuberculosis can be diagnosed intraoperatively through the use of frozen section in conjunction with clinical features. [5] Ascitic fluid ADA activity may be a useful marker for diagnosis of peritoneal tuberculosis. [6] Several studies reported 100% sensitivity for the diagnosis of peritoneal tuberculosis, with specificities in the range of 92 – 100%. [7],[8] An elevated ADA level (> 32U/L) in ascitic fluid could obviate the need for more invasive and expensive diagnostic tests. Although false negative results may occur when the ascitic fluid total protein concentration is low as in cirrhosis [7] in countries with a high incidence of tuberculosis and in high risk patient's ascitic fluid ADA might be a useful screening test. CA 125, which is a tumor-associated antigen, is a nonspecific marker of ovarian cancer and may cause confusion, as it is elevated in a variety of conditions such as infections, tuberculosis, endometriosis, Meigs syndrome, menstruation, ovarian hyper stimulation, and a number of non-gynecologic conditions like active hepatitis, acute pancreatitis, pericarditis, pneumonia, etc. [9] If pelvic-peritoneal tuberculosis is suspected, histological examination of premenstrual endometrial biopsies or curettage may yield granuloma in 50 – 70% of cases. PCR for mycobacterium tuberculosis complex of ascitic fluid obtained by ultrasound-guided fine needle aspiration is a reliable method for its diagnosis and should at least be attempted before surgical intervention. [10] If these tests are negative, laparoscopy may be performed to obtain tissue for histological diagnosis. ATT alone may be an effective treatment in pelvic-peritoneal tuberculosis, obviates the need for invasive methods. Indications for surgery include persistence of pelvic mass and recurrence of pain or bleeding after 9 months of treatment. [11]


   Conclusion Top


Medical awareness of peritoneal tuberculosis is still lacking and many women with this disease are initially thought to have ovarian malignancy and undergo unnecessary extended surgery and majority of the cases of peritoneal tuberculosis are diagnosed intraoperatively. My aim to report this case is to guide all the physicians about the diversity of the symptom and sign of tuberculosis. Tuberculosis is one infection that can mimic with any other diseases, so in developing countries tuberculosis is always been as a differential diagnosis as in any chronic illness. The negative results of usual test done for tuberculosis like ESR, ADA, AFB staining, mantouxtest (tuberculin test) does not rule out the diagnosis of tuberculosis, biopsy is the gold standard test, hence those patients who are under the high suspicion of tuberculosis, should diagnose the tuberculosis with biopsy and histopathological examination, therefore these test should be performed before surgery to exclude peritoneal tuberculosis, so that invasive and expensive surgery could be avoided and treat with ATTwith appropriate doses and duration.

 
   References Top

1.Gondal KM, Khan AF.Changing pattern of abdominal tuberculosis. Pak J Surg, 1995;11:109-13.  Back to cited text no. 1
    
2.Naz F, Chaudhary ZA, Haq A, Ahad A. Abdominal tuberculosis, A review of 25 cases Ann King Edward Med Coll 1999; 5: 180-3.  Back to cited text no. 2
    
3.Cock NJ. Treatment of tuberculosis. Br Med J 1985;6: 494-97.  Back to cited text no. 3
    
4.Kapoor VK. Kochs or Crohn's. Int J Clin Pract 1997;51:246-7.  Back to cited text no. 4
[PUBMED]    
5.Koc S, Beydilli G, Tulunay G, Ocalan R, BoranN, Ozgul N, et al. Peritoneal tuberculosis mimicking advancedovarian cancer: A retrospective review of 22 cases. Gynecol Oncol 2006;103:565-9.   Back to cited text no. 5
    
6.Uzunkoy A, Harma M, Harma M. Diagnosis ofabdominal tuberculosis: Experience from 11 cases and review of the literature. World J Gastroenterol 2004;10:3647-9.  Back to cited text no. 6
[PUBMED]    
7.Fernandez- Rodriguez CM, Perez-Arguelles BS,LedoL,Garcia- Vila LM, Pereira S, Rodriguez- Martinez D. Ascites adenosine deaminase activity is dcreased in tuberculous ascites with low protein content. Am J Gastroenterol 1991; 86: 1500-3.  Back to cited text no. 7
    
8.Gupta VK, Mukherjee S, Dutta SK, Mukherjee P. Diagnostic evaluation of ascitic adenosine deaminase tubercular peritonitis. J Assoc physicians India 1992;40: 387-9.  Back to cited text no. 8
[PUBMED]    
9.Chavhan GB,Hira P, Rathod K, Zacharia TT, Chawala A, Badhe P, et al. Female genital tuberculosis: hysterosalpingographic appearances. BrJ Radiol 2004;77:164-9.  Back to cited text no. 9
    
10.Sinha S, Chidamberan-Pillai S. Pelvic tuberculosis: An uncommongynaecological problem presenting asovarian mass. BJOG 2000;107:139-40.  Back to cited text no. 10
    
11.Hassoun A, Jacquette G, Huang A, Anderson A,Smith MA. Female genital tuberculosis: uncommon Presentation of tuberculosis in the United States. AmJ Med 2005;118:1295-6.  Back to cited text no. 11
    

Top
Correspondence Address:
Amit N Gupta
Department of Medicine, Kasturba Medical College, Manipal, Karnataka
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1755-6783.115177

Rights and Permissions


    Figures

  [Figure 1]



 

Top
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Email Alert *
    Add to My List *


    Abstract
   Introduction
   Case Report
   Discussion
   Conclusion
    References
    Article Figures

 Article Access Statistics
    Viewed5067    
    Printed89    
    Emailed1    
    PDF Downloaded15    
    Comments [Add]    

Recommend this journal