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 Abdominopelvic imaging is often inconclusive and can

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 socio-
economics, 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: sabaimtiaz@hotmail.com
Received July 10, 2010; accepted December 26, 2011.
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 micro-
biology 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 abdomino-
pelvic 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): 113-115 113
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 3a: 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 multi-
nucleated giant cells with epitheloid
histiocytes forming necrotizing
granulomas.
114
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 3b: Coronal image of
contrast enhanced CT scan of
pelvis showing complex right
adnexal mass with extensive
omental and peritoneal stranding.
Figure 4b: Histopathology at high
power magnification reveal multi-
nucleated giant cells with epitheloid
histiocytes forming necrotizing
granulomas.
Journal of the College of Physicians and Surgeons Pakistan 2012, Vol. 22 (2): 113-115
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 stran-
dings (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, HCG and LDH were within normal range.
Suspecting an ovarian malignancy a diagnostic laparo-
scopy was done which revealed widespread nodules in
Pelvic-peritoneal tuberculosis mimicking ovarian cancer
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 granulo-
matous 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.
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. Consi-
dering 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.
Chest X-ray in all such cases should be done and
looked at with suspicion for any abnormality suggestive
of previous tuberculosis. In all suspected cases of
pelvic-peritoneal tuberculosis the abdominopelvic CT
scan show similar findings of ascites, peritoneal
nodularity, mesenteric and omental thickening, cystic or
solid adnexal mass which may lead to an erroneous
preliminary diagnosis of disseminated ovarian cancer.
Serum CA-125 levels are non-specific and may give a
positive result in any abdominopelvic inflammatory
condition. Ascitic fluid or pleural fluid ZN staining for acid
fast bacilli may be helpful.
Various investigations have been suggested as the
gold standard for the diagnosis of abdominopelvic
tuberculosis but despite their clinical utility these
techniques often show poor sensitivity and specificity.
Diagnostic laparoscopy is safe, detects pathognomonic
signs of scattered yellow white nodules on visceral
peritoneum, adhesions, thickening and hyperemia of
omentum and miliary granulations. The biopsies from
miliary nodules or frozen section of specimens can
reveal epitheloid granulomas with central caseous
necrosis.4 According to large series studying laparo-
scopic evaluation combined with peritoneal biopsy, a
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Journal of the College of Physicians and Surgeons Pakistan 2012, Vol. 22 (2): 113-115
definitive diagnosis can be established in 80-94%
cases. The sensitivity of peritoneal biopsy by laparo-
scopy 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
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.
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