Pelvic-Peritoneal Tuberculosis Mimicking Ovarian Cancer

CASE REPORT

Pelvic-Peritoneal Tuberculosis Mimicking Ovarian Cancer Saba Imtiaz1, Neelam Siddiqui1, Murtaza Ahmad2 and Amna Jahan3

ABSTRACT Pelvic-peritoneal tuberculosis is a common extrapulmonary site in young females mimicking an advanced ovarian malignancy. We present 2 cases with the classical triad of advanced-stage ovarian carcinoma-ascites, abdominopelvic masses and elevated serum CA-125 levels. Laparoscopic examination revealed peritoneal nodules which on biopsy showed granulomatous inflammation and no malignant cells. Patients were started on anti-tuberculous therapy and on follow-up their symptoms as well as CA-125 levels normalized. Medical awareness of peritoneal tuberculosis is lacking and many young women with this disease undergo unnecessary extended surgery. Diagnostic laparoscopy combined with peritoneal biopsy seems to be a sufficient and safe method to provide a definitive diagnosis for this curable infection. If left untreated, the disease may disseminate and result in significant organ dysfunctions particularly infertility. Key words:

Pelvic-peritoneal tuberculosis. Advanced ovarian cancer. CA-125 levels.

INTRODUCTION Tuberculosis (TB) is a curable infective disease caused by Mycobacterium tuberculosis (MTB). In recent years it has emerged as a major public health problem in developed as well as underdeveloped countries alike. The incidence of TB is growing owing to poor socioeconomics, the spread of HIV infection, multi-drug resistance and poor case findings.1 Pakistan ranks 8th amongst the countries with highest burden of TB in the world. It has been seen that 75% patients with this disease are in their productive age group.1,2 Lung is the most common site of infection but extra pulmonary disease is becoming more prevalent.3 Extra pulmonary tuberculosis (EPTB) constitutes about 15-20% of all cases of TB.4 Pelvic-peritoneal tuberculosis is a common extrapulmonary site and a known cause of infertility and death in young healthy women if not diagnosed and treated promptly. Pelvic-peritoneal tuberculosis presents classically with a dull abdominopelvic pain, menstrual disturbances or infertility and constitutional symptoms like low-grade fever, loss of appetite, loss of weight and lethargy. It can clinically mimic an advanced abdominopelvic malignancy in females. Lack of awareness about such atypical presentation of tuberculosis can lead to a delayed diagnosis, inappropriate treatment and increased morbidity and mortality.3,5 Department of Medical Oncology1/Radiology2/Pathology3, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore. Correspondence: Dr. Saba Imtiaz, Fellow, Medical Oncology, Shaukat Khanam Memorial Cancer Hospital and Research Centre, 7-A, Block-3, Jauhar Town, Lahore. E-mail: [email protected] Received July 10, 2010; accepted December 26, 2011.

Abdominopelvic imaging is often inconclusive and can be misleading. Nodular peritoneal thickening, omental involvement, ascites, adnexal masses with both solid and cystic components are more suggestive of peritoneal metastatic carcinoma or a locally advanced ovarian cancer rather than a tuberculous peritonitis.3,6 The absence of acid fast bacilli in ascitic fluid does not exclude pelvic tuberculosis, however, the presence of lymphocyte predominant exudate provides a subtle clue towards the chronic infection. Serum CA-125 levels are found to be elevated in up to 82% of women with late stage epithelial ovarian cancer.6 It may be elevated in several benign pelvic pathologies like uterine fibroids, endometriosis, and pelvic tuberculosis and, therefore, has a limited diagnostic value and must be interpreted with caution in any pelvic-peritoneal pathology.3,6 These findings are often ignored and lead to hasty decision in favour of laparotomy for ovarian malignancy.3 The final diagnosis is established by histopathology or microbiology of the tissue involved. When promptly diagnosed, it is one of the few diffuse peritoneal processes for which there is effective therapy, with excellent prognosis.7 Here we present 2 cases where young unmarried females were referred from an outside medical facility to our tertiary care cancer centre with non-specific abdominopelvic features resembling an advanced pelvic malignancy.

CASE REPORT CASE 1: A 24 years unmarried female presented in the medical oncology outpatient department with a 2 months history of abdominal pain, altered bowel movements, abdominal distension, loss of energy and loss of weight. On clinical examination patient was a young female, weighed 48 kgs, afebrile and had distended abdomen with shifting dullness.

Journal of the College of Physicians and Surgeons Pakistan 2012, Vol. 22 (2): 113-115

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Saba Imtiaz, Neelam Siddiqui, Murtaza Ahmad and Amna Jahan

Figure 1a: Coronal image on contrast enhanced CT scan of abdomen pelvis shows matted bowel loops with extensive omental arborisation.

Figure 2a: Histopathology at low power magnification shows well formed necrotizing granulomas with multinucleated giant cells.

Figure 1b: Axial image on contrast enhanced CT scan of abdomen pelvis shows matted bowel loops with extensive omental arborisation.

Figure 2b: Histopathology at high power magnification shows well formed necrotizing granulomas with multinucleated giant cells.

Figure 3a: Coronal image of contrast enhanced CT scan of pelvis showing complex right adnexal mass with extensive omental and peritoneal stranding.

Figure 3b: Coronal image of contrast enhanced CT scan of pelvis showing complex right adnexal mass with extensive omental and peritoneal stranding.

Figure 4a: Histopathology at low power magnification reveal multinucleated giant cells with epitheloid histiocytes forming necrotizing granulomas.

Figure 4b: Histopathology at high power magnification reveal multinucleated giant cells with epitheloid histiocytes forming necrotizing granulomas.

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Her initial work-up included complete blood counts, routine chemistry, renal function tests, liver function tests and urine analysis; all of which were within normal range. Her chest X-ray was reported to have an indeterminate lung nodule. CT scan of abdomen and pelvis with contrast revealed bilateral adnexal masses 4 x 2 cm each with both solid and cystic components. The adjacent bowel loops were matted together and there was extensive omental disease with moderate ascites (Figure 1a and 1b). Serum CA-125 level was 268 U/ml (normal range 0 - 35 U/ml) while BHCG, AFP and LDH were within normal range. A diagnostic ascitic tap revealed inflammatory exudate with lymphocytic predominance but no malignant cells. In view of the adnexal mass, ascites and elevated CA-125 the probability of an advanced ovarian carcinoma was considered. Patient underwent diagnostic laparoscopy which revealed scattered nodules all over the parietal peritoneum and surface of small and large bowel. A mass in the left adnexa was visualized and mild ascites was documented. The differential diagnosis was between disseminated miliary tuberculosis vs. carcinoma peritonium. Peritoneal biopsies were taken and histopathological examination revealed focal necrotizing granulomatous inflammation. Ziehl Neelson and GMS stains were negative on the smears and no malignant cells were found. Patient was then referred for infectious disease consultation and started on four-drug antituberculous therapy (ATT). Later the MTB culture came positive on the peritoneal tissue. After 2 months she was switched to two-drugs. Eight months on ATT, she had regained health and her CA-125 level had normalized. CASE 2: A 23 years unmarried female was seen in the medical oncology outpatient department with one and a half months history of low grade fever, dull abdominal ache and oligomenorrhea. She had anorexia and had lost 4 kgs of weight in one month. On clinical examination, she appeared thin, had distended abdomen with shifting dullness and fluid thrill but no palpable mass or visceromegaly. Her routine haematology, blood chemistry and urine analysis were within normal range. Her chest X-ray revealed minimal left sided pleural effusion. CT scan of abdomen and pelvis with contrast revealed a complex right adnexal mass 4 x 5 cm, moderate ascites and peritoneal strandings (Figures 3a and 3b). Diagnostic pleurocentesis and peritoneocentesis showed inflammatory exudates with lymphocytic predominance but no malignant cells or acid fast bacilli on smear and culture. CA-125 level was 253 U/ml (normal range 0 - 35 U/ml). Other tumour markers AFP, βHCG and LDH were within normal range. Suspecting an ovarian malignancy a diagnostic laparoscopy was done which revealed widespread nodules in


Pelvic-peritoneal tuberculosis mimicking ovarian cancer

definitive diagnosis can be established in 80-94% cases. The sensitivity of peritoneal biopsy by laparoscopy may reach upto 100%.8 Other methods like DNA extraction by PCR or ELI spot (enzyme linked immunospot) on the frozen section specimens obtained by laparoscopy can be helpful, but time and cost consuming.4

the peritoneum, bowel loops were matted together and right adnexal mass was difficult to separate from the right ovary. Peritoneal biopsies were submitted for histopathology which showed necrotizing granulomatous inflammation (Figures 4a and 4b). Ziehl Neelson and GMS stains were negative. Patient was started on ATT and the culture reports confirmed MTB after 8 weeks. Patient to-date is doing well and has regained her weight and energy.

In the past decades, numerous pelvic peritoneal tuberculoses cases were misdiagnosed as advanced ovarian cancer and young females were un-necessarily subjected to extensive surgery.7,9 There is enough data to change the clinical approach to a safer, rapid and sufficient mode of diagnostic modality for the treatment of a curable infectious disease.

DISCUSSION The clinical triad of abdominal pain, ascites and adnexal mass along with raised CA-125 levels in young women should raise the suspicion of pelvic tuberculosis especially in countries with high prevalence. Considering the provisional diagnosis of ovarian carcinoma, one is prompted to undertake a radical surgery, which in the above cases and alike would be associated with both immediate and long-term morbidities. For the diagnosis of pelvic-peritoneal tuberculosis, imaging findings can be misleading and laboratory assays like the vague symptom may not help either.

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