Peritoneal tuberculosis mimicking advanced ovarian carcinoma: an important differential diagnosis to consider

BMC Research Notes

Pearse A Sylvester²  Nazreen A Bhim²  Gordon V Narayansingh²  Dylan Narinesingh³  Maria A Gosein¹ 

[1] Department of Radiology, San Fernando General Hospital, San Fernando, Trinidad;Department of Oncology, San Fernando General Hospital, San Fernando, Trinidad;Department of Medicine, University of the West Indies, St. Augustine, Trinidad

关键词: Adnexal mass;    Ascites;    CA125;    Mimic ovarian carcinoma;    Abdominal disseminated tuberculosis;   

Others  :  1143300
DOI  :  10.1186/1756-0500-6-88

 received in 2012-12-17, accepted in 2013-03-06,  发布年份 2013

【 摘 要 】

Background

Female patients who present with ascites, adnexal masses and elevated CA125 levels are typically presumed to have advanced ovarian carcinoma. This can lead to radical surgery with its associated morbidity. An important differential diagnosis to consider is tuberculous peritonitis which can present in a similar manner and responds well to medical treatment.

Case presentation

A 44 year old female presented with abdominal distension, weight loss and low grade fever. Her CA125 level was 909 U/ml. Imaging studies revealed an adnexal lesion and ascites. The lungs appeared normal and a Mantoux test was negative. Ovarian malignancy was highly suspected. Cytology of ascites was negative for malignant cells. The patient subsequently developed a large pleural effusion which was drained and negative for malignant cells and acid fast bacilli. Repeat imaging revealed a ‘tree in bud’ appearance of the lung parenchyma and dense ascites. Histology from diagnostic laparotomy revealed caseating granulomas with epithelioid cells and Langhan’s type giant cells. The patient responded well to antituberculosis therapy with normalization of CA125 levels, confirming the diagnosis of peritoneal tuberculosis.

Conclusion

CA125 levels lack specificity, with elevated levels encountered in many benign and malignant conditions, including tuberculosis. There are a few discriminating features that suggest a diagnosis of tuberculous peritonitis rather than ovarian carcinoma. Apart from chest findings which may not always be present, smooth peritoneal thickening and a dirty omentum on CT favours a diagnosis of peritoneal tuberculosis compared with nodular thickening of the peritoneum and omentum in peritoneal carcinomatosis. PCR and ADA testing of ascitic fluid can also be helpful. When these tests are negative or unavailable then diagnostic laparoscopy or laparotomy should be performed with the aid of frozen section to avoid unnecessary radical surgery in cases of peritoneal tuberculosis.

【 授权许可】

   
2013 Gosein et al; licensee BioMed Central Ltd.

【 图 表 】

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【 参考文献 】

• [1]Figueroa-Munoz J, Ramon-Pardo P: Tuberculosis control in vulnerable groups. Bull World Health Organ 2008, 86(9):657-736.
• [2]Devi L, Tandon R, Goel P, Huria A, Saha PK: Pelvic tuberculosis mimicking advanced ovarian malignancy. Trop Doct 2012, 42(3):144-146.
• [3]Oge T, Ozalp SS, Yalcin OT, Kabukcuoglu S, Kebapci M, Arik D, Isikci T: Peritoneal tuberculosis mimicking ovarian cancer. Eur J Obstet Gynecol Reprod Biol 2012, 162(1):105-108.
• [4]Xi X, Shuang L, Dan W, Ting H, Han MY, Ying C, Quan M, Sun C, Chen Z, Cui F, Ming C, Zhou JF, Xuan WS, Lu YP, Ma D: Diagnostic dilemma of abdominopelvic tuberculosis:a series of 20 cases. J Cancer Res Clin Oncol 2010, 136(12):1839-1844.
• [5]Hasanzadeh M, Malekoti H: Miliary tuberculosis peritonitis mimicking advanced ovarian cancer. Cancer Therapy 2005, 3:29-30.
• [6]Boss JD, Shah CT, Oluwole O, Sheagren JN: TB peritonitis mistaken for ovarian carcinomatosis based on an elevated CA-125. Case Report Med 2012 2012, 2012:215293.
• [7]Zaidi SN, Conner M: Disseminated peritoneal tuberculosis mimicking metastatic ovarian cancer. South Med J 2001, 94(12):1212-1214.
• [8]Shen-Gunther J, Mannel RS: Ascites as a predictor of ovarian malignancy. Gynecol Oncol 2002, 87(1):77-83.
• [9]Vagenas K, Stratis C, Spyropoulos C, Spiliotis J, Petrochilos J, Kourea H, Karavias D: Peritoneal carcinomatosis versus peritoneal tuberculosis: a rare diagnostic dilemma in ovarian masses. Cancer Ther 2005, 3:489-494.
• [10]Moss EL, Hollingworth J, Reynolds TM: The role of CA125 in clinical practice. J Clin Pathol 2005, 58:308-312.
• [11]Le Thi HD, Mohattane H, Piette JC: Specificity of CA 125 tumor marker. A study of 328 cases of internal medicine. Presse Med 1988, 17(43):2287-2291.
• [12]Piura B, Rabinovich A, Leron E, Yanai-Inbar I, Mazor M: Peritoneal tuberculosis mimicking ovarian carcinoma with ascites and elevated serum CA-125: case report and review of literature. Eur J Gynaecol Oncol 2002, 23(2):120-122.
• [13]Markman M: The role of CA-125 in the management of ovarian cancer. Oncologist 1997, 2(1):6-9.
• [14]Bhattacharyya SK, Mandal A, Thakur SB, Mukherjee S, Saha SK, Ghoshal AG: Radiological evaluation of chest in abdominal tuberculosis. J Clin Diagn Res 2011, 5(5):926-928.
• [15]Lee WK, Van Tonder F, Tartaglia CJ, Dagia C, Cazzato RL, Duddalwar VA, Chang SD: CT appearances of abdominal tuberculosis. Clin Radiol 2012, 67(6):596-604.
• [16]Uzunkoy A, Harma M, Harma M: Diagnosis of abdominal tuberculosis: experience from 11 cases and review of the literature. World J Gastroenterol 2004, 10(24):3647-3649.
• [17]Riquelme A, Calvo M, Salech F, Valderrama S, Pattillo A, Arellano M, Arrese M, Soza A, Viviani P, Letelier LM: Value of adenosine deaminase (ADA) in ascitic fluid for the diagnosis of tuberculous peritonitis: a meta-analysis. J Clin Gastroenterol 2006, 40(8):705-710.