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 Table of Contents  
Year : 2021  |  Volume : 5  |  Issue : 2  |  Page : 66-69

Genital tuberculosis: A great masquerader of ovarian malignancy and peritoneal carcinomatosis

1 Indira Gandhi Medical College and Research Institute, Puducherry, India
2 Dept of Obstetrics and Gynecology, All India Institute of Medical Sciences, Mangalagiri, Andhra Pradesh, India

Date of Submission14-Sep-2020
Date of Acceptance05-May-2021
Date of Web Publication22-Dec-2021

Correspondence Address:
Vijayan Sharmila
All India Institute of Medical Sciences, Mangalagiri, Andhra Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijcpc.ijcpc_15_20

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Malignancies of genital tract is a worrisome condition due to its aggressiveness and complicated treatment modality. Lesions of the genital tract mimicking malignancy have to be diagnosed preoperatively to avoid unnecessary extensive surgery. High index of suspicion is required from clinician, radiologist, and pathologist to accurately diagnose malignant mimicking lesions in preoperative period. We report a case of 40-year-old multiparous female with bilateral adnexal mass, peritoneal nodules, and ascites mimicking advanced ovarian malignancy, diagnosed to have a common benign treatable condition by histopathological examination. This article emphasizes on the need for thorough investigation to diagnose benign lesions that mimic malignancy.

Keywords: Ascites, genital tuberculosis, ovarian malignancy, peritoneal nodules

How to cite this article:
Balakrishnan P, Sharmila V, Babu TA. Genital tuberculosis: A great masquerader of ovarian malignancy and peritoneal carcinomatosis. Int J Clinicopathol Correl 2021;5:66-9

How to cite this URL:
Balakrishnan P, Sharmila V, Babu TA. Genital tuberculosis: A great masquerader of ovarian malignancy and peritoneal carcinomatosis. Int J Clinicopathol Correl [serial online] 2021 [cited 2022 Jan 19];5:66-9. Available from: https://www.ijcpc.org/text.asp?2021/5/2/66/333390

  Introduction Top

Bilateral adnexal masses with ascites in a female is a challenging scenario because there is high rate of misdiagnosis of underlying cause. Clinicians have to consider all the causes which lead to this scenario to avoid extensive surgery in benign lesions and inadequate treatment in malignant lesions. The nature of causes varies from non-infectious and infectious etiology to extensive malignant etiology. Differential diagnoses for bilateral adnexal mass with ascites have been described in literature.[1] Among them, differentiating tuberculous peritonitis and advanced ovarian carcinoma by history, clinical features, and radiological imaging is very difficult, and cases highlighting their similarities in clinical aspects have been reported in literature. Careful radiological assessment, tumor marker evaluation, and diagnostic laparoscopy aid in differentiating these two similar appearing, but completely different entities. We report a case of 40-year-old multiparous female with adnexal mass, peritoneal nodules, and ascites that mimicked advanced ovarian carcinoma clinically and radiologically, who underwent exploratory laparotomy for the same, but later diagnosed with tuberculosis of genital tract and peritoneum by histopathological examination.

  Case Report Top

A 40-year-old multiparous female presented with complaints of progressive abdominal distension for 6 months and abdominal pain for 1 month duration. There was a history of on and off low-grade fever for the past 1 week, but no associated cough with expectoration. She had regular menstrual cycles. She was married for the past 2 years, cohabiting with husband, and had difficulty to conceive. The present patient had no previous history of tuberculosis, her family history was negative, and she denied any contact with diseased individuals. On general examination, she was afebrile. There was no pallor, icterus, pedal edema, and lymphadenopathy. Abdomen was diffusely distended with positive fluid thrill. Bimanual examination revealed a fixed uterus with bilateral adnexal masses. Urine pregnancy test was negative. Ultrasound examination showed bilateral solid ovarian masses and ascites. Chest X-ray was normal. Contrast-enhanced computed tomography (CECT) abdomen revealed bilateral solid ovarian masses of 6 cm × 5 cm × 5 cm (left) and 5 cm × 4 cm × 4 cm (right) size with calcifications. Ascites and irregular peritoneal nodules were present. CA-125 level was elevated (217 U/mL). Ascitic fluid analysis was negative for malignant cells. Pap smear was negative for intraepithelial lesion. Based on the clinical findings and investigations, a diagnosis of bilateral ovarian malignancy with peritoneal carcinomatosis was made. Exploratory laparotomy was performed, which revealed bilateral ovarian masses adherent to uterus with multiple variable sized peritoneal nodules, ascites, and omental nodules. Total abdominal hysterectomy, bilateral salpingoophorectomy and biopsy of peritoneal nodules was done. Specimens were sent for histopathological examination. Grossly uterus was normal in size with normal-appearing endometrium, myometrium, and serosa. Grossly right ovarian mass had surface whitish nodules and was gritty to cut [Figure 1]. Left ovarian mass had surface nodules with cut section showing predominant solid areas and focal cystic areas filled with serous fluid. Surprisingly, histopathological examination of the biopsied specimens showed numerous caseating granulomas consisting of epithelioid cells, macrophages, numerous Langhan, and foreign body type of giant cells [Figure 2], [Figure 3], [Figure 4], [Figure 5]. The histopathological diagnosis was suggestive of genital tuberculosis, for which she is undergoing treatment and showing remarkable improvement.
Figure 1: Right ovary of 5 cm × 4 cm × 4 cm with surface nodules

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Figure 2: Microphotograph showing numerous granulomas in myometrium (H and E, ×40)

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Figure 3: Microphotograph showing numerous epithelioid cell granulomas in cervix (H and E, ×40)

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Figure 4: Microphotograph showing extensive areas of calcifications in ovarian stroma (H and E, ×40)

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Figure 5: Microphotograph showing epithelioid granulomas in endocervix (H and E, ×400)

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  Discussion Top

Tuberculosis is a common infectious disease in developing countries routinely encountered in clinical practice. Extrapulmonary tuberculosis in the genital tract and peritoneum is very rare and has a varied and nonspecific clinical presentation. Pelvic tuberculosis in females is common in 20–40 years of age whereas ovarian carcinomas are usually occur in women above 40 years of age.[2] Our patient presented with nonspecific symptoms such as abdominal pain and abdominal distension as reported in literature.[3],[4] Our patient had solid bilateral ovarian masses and ascites on CECT scan that misguided us to diagnose of ovarian malignancy.[5] Extensive caseating necrosis in tuberculosis has resulted in dystrophic calcification of ovaries in our case. CECT findings that actually aid in diagnosing tuberculous peritonitis are dense loculated ascites, smooth thickening and enhancement of peritoneum, dense enhancing lymphadenopathy, and mesenteric strands.[2],[4],[6] CA 125 levels being a nonspecific marker are elevated in peritoneal and epithelial ovarian malignancies as well as in benign chronic inflammatory conditions of peritoneum such as tuberculosis.[7] HE4 (human epididymis protein 4), a sensitive tumor marker for serous epithelial malignancy of ovary, will be elevated in both tuberculosis and ovarian malignancy. A study conducted by Zhang in 2006 evaluated clinical significances of serum HE4 and CA125 level in tuberculous peritonitis and epithelial ovarian malignancy. The study concluded that optimal cutoff values of HE4 >151.4 pmol/l and CA-125 >563.5 U/ml should be considered to differentiate between these two conditions. Values lower than the cuttoff points towards tuberculosis while higher levels suggest malignancy.[8] Our patient had CA125 level of 217 U/ml (less than cutoff value) due to tuberculous peritonitis. Ascitic fluid analysis for malignant cells, culture of acid-fast bacilli, and acid-fast stain has high false negative rate, which may not be useful in differentiating these two lesions. Adenosine deaminase (ADA) assay with a cutoff of 21 IU/L and reverse transcription polymerase chain (PCR) of ascitic fluid to detect mycobacterium bacilli may help in early diagnosis.[9] Our patient had negative malignant cytology of ascitic fluid. ADA assay was not done as the patient could not afford. Diagnostic laparoscopy and biopsy proves to be the best preoperative minimally invasive investigation that definitely diagnoses the granulomatous inflammation in tuberculosis.[7],[9] The definitive diagnosis lies on histopathological examination, identifying tubercle bacilli by microbiological examination including culture and PCR.[4] The management for genital tuberculosis is mainly medical line of treatment and most of the cases resolve with antitubercular therapy. To avoid devastating consequences, high index of clinical suspicion for genital tuberculosis as well as early diagnosis and treatment is warranted in all such women presenting with nonspecific clinical symptoms, adnexal masses, peritoneal nodules, and ascites, especially in developing countries.

  Conclusion Top

We reported a case of genital tuberculosis in a 40-year-old multiparous female mimicking advanced ovarian malignancy based on clinical and radiological findings. The diagnosis of genital tuberculosis remains difficult due to its nonspecific features. This case highlights the importance of considering genital tuberculosis as a differential diagnosis in all cases with non-specific abdominal pain, adnexal mass, peritoneal nodules, and ascites, particularly in developing countries.

Informed consent

Patient consent was obtained.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initial will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Su MH, Cho SW, Kung YS, Lin JH, Lee WL, Wang PH. Update on the differential diagnosis of gynecologic organ-related diseases in women presenting with ascites. Taiwan J Obstet Gynecol 2019;58:587-91.  Back to cited text no. 1
Wu CH, Changchien CC, Tseng CW, Chang HY, Ou YC, Lin H. Disseminated peritoneal tuberculosis simulating advanced ovarian cancer: A retrospective study of 17 cases. Taiwan J Obstet Gynecol 2011;50:292-6.  Back to cited text no. 2
Chien JC, Fang CL, Chan WP. Peritoneal tuberculosis with elevated CA-125 mimicking ovarian cancer with carcinomatosis peritonei: Crucial CT findings. EXCLI J 2016;15:711-5.  Back to cited text no. 3
Fahmi MN, Harti AP. A diagnostic approach for differentiating abdominal tuberculosis from ovarian malignancy: A case series and literature review. BMC Proc 2019;13:13.  Back to cited text no. 4
Burkill GJ, Allen SD, A'hern RP, Gore ME, King DM. Significance of tumour calcification in ovarian carcinoma. Br J Radiol 2009;82:640-4.  Back to cited text no. 5
Gosein MA, Narinesingh D, Narayansingh GV, Bhim NA, Sylvester PA. Peritoneal tuberculosis mimicking advanced ovarian carcinoma: An important differential diagnosis to consider. BMC Res Notes 2013;6:88.  Back to cited text no. 6
Ding DC, Chu TY. Laparoscopic diagnosis of tuberculous peritonitis mimicking ovarian malignancy. Taiwan J Obstet Gynecol 2011;50:540-2.  Back to cited text no. 7
Zhang L, Chen Y, Liu W, Wang K. Evaluating the clinical significances of serum HE4 with CA125 in peritoneal tuberculosis and epithelial ovarian cancer. Biomarkers 2016;21:168-72.  Back to cited text no. 8
Kang SJ, Kim JW, Baek JH, Kim SH, Kim BG, Lee KL, et al. Role of ascites adenosine deaminase in differentiating between tuberculous peritonitis and peritoneal carcinomatosis. World J Gastroenterol 2012;18:2837-43.  Back to cited text no. 9


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]


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