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
Diagnosis of extra pulmonary tuberculosis is usually difficult because of varied presentation and lack of sensitive tests. , Tuberculosis has been called a great mimic, particularly so in the abdomen, where its manifestation can resemble a variety of diseases.  In most cases diagnosis is reasonably made by the process of exclusion.  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. 
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.
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.
Majority of the cases with peritoneal tuberculosis can be diagnosed intraoperatively through the use of frozen section in conjunction with clinical features.  Ascitic fluid ADA activity may be a useful marker for diagnosis of peritoneal tuberculosis.  Several studies reported 100% sensitivity for the diagnosis of peritoneal tuberculosis, with specificities in the range of 92 – 100%. , 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  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.  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.  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. 
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.
Source of Support: None, Conflict of Interest: None