Cancer Therapy Vol 3, 29-30, 2005

Miliary tuberculosis peritonitis mimicking advanced ovarian cancer

Case Report

Malihe Hasanzadeh* and Hasan Malekoti

Gynecology Oncology, Mashhad University of Medical Sciences, Mashhad, Iran.

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*Correspondence: Malihe Hasanzadeh, Obstetric Gynecology Department Cheam Hospital, Mashhad, Iran.Phon/Fax: 98-511-8409612; e-mail:Malhasanzadeh@yahoo.com

Key words: Ovarian cancer, Peritoneal Tuberculosis, Abdominal mass, CA-125

Received: 17 January 2005; Accepted: 28 January 2005; electronically published: February 2005

Summary

Primary peritoneal tuberculosis is a rare presentation of this disease. It is usually associated with ascites, raised CA-125 levels and abdominal mass. A patient with a pelvic mass, ascites, raised CA-125 underwent an exploratory laparatomy for presumed ovarian cancer. Final pathology revealed peritoneal tuberculosis without any pulmonary involvement. Acid -Fast bacilli were confirmed with polymerase chain reaction in the surgical specimen. This case demonstrated a high rate of misdiagnosis between advanced ovarian cancer and peritoneal tuberculosis. An elevated CA- 125 is not specific for ovarian malignancy.

I. Introduction

Ovarian cancer is the leading cause of death from gynecologic malignancies. Because early ovarian cancer produces few specific symptoms, most women present with advanced stage disease where the prognosis is poor. Although there have been advanced in the evaluation and treatment of ovarian cancer, most patients continue to present with advanced disease when survival is limited (Disaia and Creasman, 2002). Annual serum CA-125 levels, pelvic examination and transvaginal ultrasound are being used for screening, has not adequate sensitivity or specificity (Karl and Platt, 1995).

In advanced stages, there are many nonspecific signs and symptoms and we require surgery and pathologic evaluation for diagnosis. Tuberculosis of the peritoneum is a rare disease. There are several case reports that point to uncertainly in the preoperative differential diagnosis of peritoneal tuberculosis and advanced ovarian cancer (Lachman et al, 1985; Gurgan et al, 1993; Groutz et al, 1998).

This paper presents one additional case of peritoneal tuberculosis and emphasize that we must be careful when interpreting a positive results.

II. Case

In May 2002,a 22 year old woman(primiparous)was referred to obstetric Gynecology Department in Ghaem hospital, Mashhad, Iran.

In her first visit, she had abdominal pain and increasing abdominal girth and weigh loss (20 pound) from 3 month ago. CT-Scan showed a huge heterogenic ovarian mass (solid-cystic components). Serum CA125 was elevated at 200(u/ml). The patient had any history of fever, chills, night sweats. The patient's family history was significant for a brother who treated tuberculosis 2 year ago. Laboratory data revealed a normal white blood cell count. A preoperative chest X-ray was normal. The patient underwent an exploratory laparatomy.We could not enter to abdominal cavity. There are disseminated nodules in the peritoneum of the parietal wall.

The specimen send to pathologic department, frozen section was performed. Pathology revealed chronic granulomatous changes and no malignancy.

Post operatively all sputum samples, blood cultures and peritoneal fluid analyses were negative for acid-fast bacilli. Polymerase chain reaction was positive for acid-fast bacilli in the surgical tissue specimen. The patient was treated with Isoniazid, Rifampicin, Pyrazinamide and Etamburol.

After 4 months, in her visit abdominal mass was disappeared. Treatment continued for 1 year.

III. Discussion

This patient is a case of tuberculosis peritonitis diagnosed with tissue pathology. Peritoneal tuberculosis is one of the generalized pathologies that present with nonspecific sign and symptoms such as ascites and pelvic, abdominal pain and mass, which mimic ovarian cancer (Martin and Bradsher, 1986). The pelvic tuberculosis most often in patients between the ages of 20 and 40 years. Ovarian cancer is rare before the age of 40 and peaks at age 65 to 75 (Sutherland, 1980).

An elevated serum CA-125 level in a patient with a pelvic mass and ascites raises the suspicion of ovarian cancer (Gurgan et al, 1993). Many malignancies that are not ovarian, such as endometrial and gastrointestinal adenocarcinoma,have also been associated with elevated serum CA-125 levels (Kramer et al, 1993; Simsek et al, 1996). Differential diagnosis in elevated serum CA-125 is extremely difficult and needs surgical intervention. Futhermore,elevation in CA-125 serum levels are present in a number of benign ovarian tumors, including endometrioma, inflammatory disease of the ovaries and serous cyst adenoma (Barbieri et al, 1986).

More than two thirds of the cases (tuberculosis peritonitis) are diagnosed at the time of laparatomy performed for some other diagnosis. This disease should be included in the differential diagnosis of this devastating malignancy, especially in developing countries where it remains endemic. Progression of tuberculosis peritonitis often takes months or even years. Chest Roentgenograms are not of help either in distinguishing patients with Tuberculosis peritonitis (Bhansali, 1977).

Son graphic features of tuberculosis peritonitis illustrate adenexal mass, adhesions and septated or particulate ascites (Kramer et al, 1993). In computerized tomography examination, presence of a smooth peritoneum with minimal thickening and pronounced enhancement suggest peritoneal tuberculosis, where as nodular implants and irregular peritoneal thickening suggest peritoneal carcinomatosis (Rodriguez and Pombo, 1996).

The literature reports other cases of tuberculosis peritonitis diagnosed solely by tissue pathology. Final pathology provided the crucial information and diagnosis for this patient. Frozen section can be used to confirm malignancy intraoperatively (Straughn et al, 2000). In this case frozen section would have revealed chronic granulomatous reaction and inflammation which would be consistent but not diagnostic for tuberculosis. Histology confirmation of

Tuberculosis peritonitis can be difficult, but the lack of malignant cell would have made extra ovarian carcinoma less likely.

In addition standard microscopic section, the specimen can be examined by fluorescent antibody technique. Acid-fast

Staining of tissue is effective in detecting the organism (Bilgin et al, 2001).

Tuberculosis peritonitis should be considered in the differential diagnosis of a patient with pelvic mass and elevated CA-125.

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