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Abdominal tuberculosis mimicking metastatic ovarian carcinoma
Abdominal tuberculosis mimicking metastatic ovarian carcinoma William P. Irvin, Jr, MD, Laurel W. Rice, MD, and Willie A. Andersen, MD A resurgence of abdominal tuberculosis has occurred recently,1 although it was formerly a relatively infrequent disease in the United States. Individuals with the greatest risk of tuberculosis are those with acquired immunodeficiency syndrome (AIDS); immigrants from high AIDS prevalence regions such as sub-Saharan Africa, Southeast Asia, and Haiti; the urban poor; the homeless; and the elderly, particularly those in nursing homes.2 The symptoms and signs of abdominal tuberculosis can be nonspecific. Given its resurgence, this disease must be considered in the differential diagnosis of abdominal pain, mass, and ascites.
laboratory abnormality was an ovarian cancer antigen 125 assay of 125,995 U/mL (normal range 1–35 U/mL). The patient underwent exploratory laparotomy for presumed ovarian malignancy. When the abdomen was entered, 3 liters of ascites were encountered; both hemidiaphragms were studded with numerous small, whitened plaques; and a clear gelatinous material was observed throughout the abdomen. The liver, spleen, kidneys, pancreas, and gallbladder were normal in appearance. The pelvis was remarkable for a 5 3 5 3 3-cm multiloculate, complex left ovarian mass and a 2 3 3-cm firm, mobile, right external iliac node. A total abdominal hysterectomy and bilateral salpingo-oophorectomy, appendectomy, subtotal omentectomy, and right pelvic lymph node sampling were done. Intraoperative frozen section showed multiple caseating granulomata involving the ovaries and fallopian tubes bilaterally, and the final histologic report confirmed necrotizing granulomatous salpingitis in both fallopian tubes and serosal granulomata of the ovaries and appendix. Ascitic fluid culture grew out Mycobacterium tuberculosis. The patient was discharged from the hospital on quadruple drug therapy (isoniazid, rifampin, pyrazinamide, and ethambutol) for 7 months. She remains alive and well today.
Comment Case A 41-year-old white woman, gravida 2, para 2, employed as a nurse in a regional dialysis facility, was evaluated by her local physician for a 3-month history of left lower quadrant pain, pelvic pressure, satiety, eructation, and an involuntary 10pound weight gain. Her medical history was remarkable for hepatitis A infection. Her surgical and family histories were unremarkable. Her obstetric history was remarkable for a 4-year period of secondary infertility after the birth of her first child. Ultrasound showed a 6-cm complex, multiseptate, left adnexal mass with moderate ascites and she was referred. Vital signs were normal and physical examination showed extensive ascites, a 4 3 5 cm firm, mobile, nontender, left adnexal mass, and multiple tiny, irregular implants lining the floor of the cul-de-sac. Radiographic studies included chest x-ray with fibrotic changes in both apices, hilar retraction, and bilateral small pleural effusions. Abdominal and pelvic computed tomography indicated ascites, a 5-cm complex, left adnexal mass, and mild, right periaortic lymphadenopathy. The only From the Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Virginia Medical Center, Charlottesville, Virginia.
VOL. 92, NO. 4, PART 2, OCTOBER 1998
Patients with abdominal tuberculosis can present with signs and symptoms suggestive of metastatic malignancy, including pain, weight loss, anorexia, nausea, a palpable abdominal mass, elevated ovarian cancer antigen 125, and peritoneal implants. When abdominal tuberculosis is suspected, tubercle tissue biopsy for histologic evaluation, acid fast stain, and culture and sensitivity should be obtained for accurate and timely diagnosis.
References 1. Snider DE Jr, Roper WL. The new tuberculosis. N Engl J Med 1992;326:703–5. 2. Rieder HL, Cauthen GM, Kelly GD. Tuberculosis in the United States. JAMA 1989;262:385–9.
Received March 4, 1998. Received in revised form April 30, 1998. Accepted May 22, 1998. Copyright © 1998 by The American College of Obstetricians and Gynecologists. Published by Elsevier Science Inc.
0029-7844/98/$19.00 PII S0029-7844(98)00227-0
709
laboratory abnormality was an ovarian cancer antigen 125 assay of 125,995 U/mL (normal range 1–35 U/mL). The patient underwent exploratory laparotomy for presumed ovarian malignancy. When the abdomen was entered, 3 liters of ascites were encountered; both hemidiaphragms were studded with numerous small, whitened plaques; and a clear gelatinous material was observed throughout the abdomen. The liver, spleen, kidneys, pancreas, and gallbladder were normal in appearance. The pelvis was remarkable for a 5 3 5 3 3-cm multiloculate, complex left ovarian mass and a 2 3 3-cm firm, mobile, right external iliac node. A total abdominal hysterectomy and bilateral salpingo-oophorectomy, appendectomy, subtotal omentectomy, and right pelvic lymph node sampling were done. Intraoperative frozen section showed multiple caseating granulomata involving the ovaries and fallopian tubes bilaterally, and the final histologic report confirmed necrotizing granulomatous salpingitis in both fallopian tubes and serosal granulomata of the ovaries and appendix. Ascitic fluid culture grew out Mycobacterium tuberculosis. The patient was discharged from the hospital on quadruple drug therapy (isoniazid, rifampin, pyrazinamide, and ethambutol) for 7 months. She remains alive and well today.
Comment Case A 41-year-old white woman, gravida 2, para 2, employed as a nurse in a regional dialysis facility, was evaluated by her local physician for a 3-month history of left lower quadrant pain, pelvic pressure, satiety, eructation, and an involuntary 10pound weight gain. Her medical history was remarkable for hepatitis A infection. Her surgical and family histories were unremarkable. Her obstetric history was remarkable for a 4-year period of secondary infertility after the birth of her first child. Ultrasound showed a 6-cm complex, multiseptate, left adnexal mass with moderate ascites and she was referred. Vital signs were normal and physical examination showed extensive ascites, a 4 3 5 cm firm, mobile, nontender, left adnexal mass, and multiple tiny, irregular implants lining the floor of the cul-de-sac. Radiographic studies included chest x-ray with fibrotic changes in both apices, hilar retraction, and bilateral small pleural effusions. Abdominal and pelvic computed tomography indicated ascites, a 5-cm complex, left adnexal mass, and mild, right periaortic lymphadenopathy. The only From the Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Virginia Medical Center, Charlottesville, Virginia.
VOL. 92, NO. 4, PART 2, OCTOBER 1998
Patients with abdominal tuberculosis can present with signs and symptoms suggestive of metastatic malignancy, including pain, weight loss, anorexia, nausea, a palpable abdominal mass, elevated ovarian cancer antigen 125, and peritoneal implants. When abdominal tuberculosis is suspected, tubercle tissue biopsy for histologic evaluation, acid fast stain, and culture and sensitivity should be obtained for accurate and timely diagnosis.
References 1. Snider DE Jr, Roper WL. The new tuberculosis. N Engl J Med 1992;326:703–5. 2. Rieder HL, Cauthen GM, Kelly GD. Tuberculosis in the United States. JAMA 1989;262:385–9.
Received March 4, 1998. Received in revised form April 30, 1998. Accepted May 22, 1998. Copyright © 1998 by The American College of Obstetricians and Gynecologists. Published by Elsevier Science Inc.
0029-7844/98/$19.00 PII S0029-7844(98)00227-0
709