Peritoneal tuberculosis with pelvic abdominal mass, ascites and elevated CA 125 mimicking advanced ovarian carcinoma: a series of 10 cases

Tuberculous peritonitis complicated by an intraperitoneal tuberculous abscess: A case report

BACKGROUND

Tuberculous peritonitis (TBP) is a chronic, diffuse inflammation of the peritoneum caused by Mycobacterium tuberculosis. The route of infection can be by direct spread of intraperitoneal tuberculosis (TB) or by hematogenous dissemination. The former is more common, such as intestinal TB, mesenteric lymphatic TB, fallopian tube TB, etc., and can be the direct primary lesion of the disease.

CASE SUMMARY

We present an older male patient with TBP complicated by an abdominal mass. The patient's preoperative symptoms, signs and imaging data suggested a possible abdominal tumor. After surgical treatment, the patient's primary diagnosis of TBP complicating an intraperitoneal tuberculous abscess was established by combining past medical history, postoperative pathology, and positive results of TB-related laboratory tests. The patient's symptoms were significantly reduced after surgical treatment, and he was discharged from the hospital with instructions to continue treatment at a TB specialist hospital and to undergo anti-TB treatment if necessary.

CONCLUSION

This case report analyses the management of TBP complicated by intraperitoneal tuberculous abscess and highlights the importance of early definitive diagnosis in the hope of improving the clinical management of this type of disease.

Peritoneal Tuberculosis With Raised Cancer Antigen 125 (CA-125) in a Post-partum Woman: A Case Report

Peritoneal tuberculosis is a common cause of ascites in areas endemic to Mycobacterium tuberculosis. The presentation of tuberculous ascites can mimic ovarian malignancy when it is associated with elevated cancer antigen 125 (CA-125) levels. We hereby discuss a case of a four months post-partum female patient who presented with gradual abdominal distension and was diagnosed with peritoneal tuberculosis after proper evaluation. She was started on anti-tubercular therapy and the treatment was successful. This case report highlights the importance of considering peritoneal tuberculosis as a differential diagnosis in cases of ascites with raised serum CA-125 levels in a Mycobacterium tuberculosis endemic region.

Spontaneous Resolution of Strangulated Small Bowel Obstruction in a Patient With Intestinal Tuberculosis After Starting Anti-tuberculosis Drugs: A Case Report

Intestinal tuberculosis can cause strangulated small bowel obstruction. Strangulated small bowel obstruction usually requires surgery. We report a case of a patient with intestinal tuberculosis, who developed a spontaneously resolving strangulated small bowel obstruction after the commencement of anti-tuberculosis drugs. A 72-year-old woman presented with abdominal pain and ascites was noticed on abdominal ultrasonography. Contrast-enhanced computed tomography (CT) revealed a 50-mm tumor in the ileocecal region that was darkly contrasted, along with peritoneal thickening and ascites. A malignant tumor and carcinomatous peritonitis were suspected. Colonoscopy showed an ulcerative lesion in the terminal ileum, and the acid-fast bacillus culture was positive; therefore, the patient was diagnosed with intestinal tuberculosis and was treated with isoniazid, rifampicin, ethambutol, and pyrazinamide. After commencing treatment, improvement in peritoneal thickening and ascites was confirmed using abdominal ultrasonography; therefore, we concluded that the ascites was due to tuberculous peritonitis. Six weeks after the initiation of treatment, the patient visited our facility with complaints of abdominal pain. Contrast-enhanced CT revealed unenhanced small intestinal walls, and a diagnosis of strangulated small bowel obstruction was made; however, her symptoms improved naturally. Strangulated small bowel obstruction was presumed to be due to the presence of bands as anti-tuberculosis therapy could promote fibrosis. In this case, abdominal ultrasonography was useful in the evaluation of the effects of treatment.

The role of "penumbra sign" and diffusion-weighted imaging in adnexal masses: do they provide a clue in differentiating tubo-ovarian abscess from ovarian malignancy?

Purpose

To evaluate the role of “penumbra sign”, diffusion-weighted imaging (DWI), and the apparent diffusion coefficient (ADC) value in differentiating tubo-ovarian abscess (TOA) from ovarian malignancy.

Material and methods

Thirty-six patients with 50 adnexal masses (tubo-ovarian abscess, n = 24; ovarian malignancy, n = 26), who underwent magnetic resonance imaging (MRI) with DWI, were retrospectively evaluated. “Penumbra sign” (hyperintense rim on T1W images), diffusion restriction, and mean apparent diffusion coefficient (ADC) values from cystic (c-ADC) and solid (s-ADC) components were evaluated for all the masses.

Results

“Penumbra sign” on T1W images was significantly more common in the TOA group (n = 21, 87.5%) than in the ovarian malignancy group (n = 2, 7.7%) (p < 0.001). Similarly, diffusion restriction in the cystic component was more frequent in the TOA group (n = 24, 100% vs. n = 2, 10.5%; p < 0.001). In contrast, diffusion restriction in the solid component was more common in the ovarian malignancy group (n = 5, 20.8% vs. n = 26, 100%; p < 0.001). The mean c-ADC value was significantly lower in TOAs (p < 0.001). A c-ADC value of 1.31 × 10^-3 mm²/s may be an optimal cut-off in distinguishing TOAs from ovarian malignancies. Conversely, the mean s-ADC value was significantly lower in the ovarian malignancy group (p < 0.001). An s-ADC value of 0.869 × 10^-3 mm²/s may be an optimal cut-off in differentiating ovarian malignancies from TOAs (p < 0.001). ROC curve analysis showed that c-ADC values had a higher diagnostic accuracy than s-ADC values.

Conclusions

“Penumbra sign” on T1W images, diffusion characteristics, and ADC values provide important clues in addition to conventional MR imaging features in differentiating TOA from ovarian malignancy.

Rhizoctonia bataticola lectin induces apoptosis and inhibits metastasis in ovarian cancer cells by interacting with CA 125 antigen differentially expressed on ovarian cells

A N-glycan specific lectin from Rhizoctonia bataticola [RBL] was shown to induce growth inhibitory and apoptotic effect in human ovarian, colon and leukemic cells but mitogenic effect on normal PBMCs as reported earlier, revealing its clinical potential. RBL has unique specificity for high mannose tri and tetra antennary N-glycans, expressed in ovarian cancer and also recognizes glycans which are part of CA 125 antigen, a well known ovarian cancer marker. Hence, in the present study diagnostic and therapeutic potential of RBL was investigated using human ovarian epithelial cancer SKOV3 and OVCAR3 cells known for differentially expressing CA 125. RBL binds differentially to human ovarian normal, cyst and cancer tissues. Flow cytometry, western blot analysis of membrane proteins showed the competitive binding of RBL and CA 125 antibody for the same binding sites on SKOV3 and OVCAR3 cells. RBL has strong binding to both SKOV3 and OVCAR3 cells with MFI of 173 and 155 respectively. RBL shows dose and time dependent growth inhibitory effect with IC₅₀ of 2.5 and 8 μg/mL respectively for SKOV3 and OVCAR3 cells. RBL induces reproductive cell death, morphological changes, nuclear degradation and increased release of ROS in SKOV3 and OVCAR3 cells leading to cell death. This is also supported by increase in hypodiploid population, altered MMP leading to apoptosis possibly involving intrinsic pathway. Adhesion, wound healing, invasion and migration assays demonstrated anti-metastasis effect of RBL apart from its growth inhibitory effect. These results show the promising potential of RBL both as a diagnostic and therapeutic agent.

Fitz-Hugh-Curtis Syndrome: An Incidental Diagnostic Finding During Laparoscopic Sterilization

Fitz-Hugh-Curtis syndrome is associated with the presence of perihepatic adhesions, with or without associated symptoms. It is, most commonly, a result of chlamydial or gonococcal infections. We present a case of Fitz-Hugh-Curtis syndrome in an asymptomatic female patient who underwent a routine laparoscopic sterilization. The patient had, otherwise, normal intraoperative findings and negative laboratory investigations. The patient had a past history of tuberculosis infection, for which she had received treatment 10 years ago. We also present the literature relevant to our case report.

Abdominal Tuberculosis Mimicking Ovarian Cancer: A Diagnostic Dilemma

Aims

The objective of this study was to describe the clinicopathological details in patients referred to the Gynaecologic Oncology Department with possible ovarian or primary peritoneal cancer where the final diagnosis turned out to be abdominal tuberculosis.

Methodology

Retrospective chart analysis of 23 cases diagnosed with abdominal tuberculosis who were admitted under the Division of Gynaecologic Oncology suspected to have disseminated peritoneal malignancy, during 2014-2017.

Results

There were 23 patients who were referred to the Gynaecologic Oncology outpatient for evaluation of ascites, to rule out malignancy. The mean age of this patient group was 35 years (SD 14.5, range 14-65). The mean CA 125 was 333.5 [400.7 (9.09-1568)]. Ascitic fluid analysis confirmed TB in 26%; omental biopsy revealed TB in 69%, and operative diagnostic procedures (laparoscopy and laparotomy) were done in 15 of the 23 patients which had a positive pick up rate of 100% to confirm the diagnosis of TB. Culture of ascitic fluid/omental tissue and PCR yields were poor with a pick up rate of 33% and 6%.

Conclusions

Abdominal TB is common in India and can mimic ovarian malignancy, and hence, high degree of suspicion needed. The isolation of AFB is the gold standard for diagnosis of pulmonary tuberculosis but has a low yield in abdominal TB. Ultrasound-guided procedure is reasonable as an initial procedure. As much time can be lost in working up these patients through multiple diagnostic algorithms using ascitic tap, USG biopsy and then an operative procedure, diagnostic laparoscopy could be considered early in the work up. It is a simple, time-saving and cost-effective way of establishing a diagnosis sooner with least complications.

A diagnostic approach for differentiating abdominal tuberculosis from ovarian malignancy: a case series and literature review

Background

Abdominal tuberculosis is an uncommon variant of extrapulmonary tuberculosis. It accounts for 3.5% of extrapulmonary tuberculosis. Diagnosis of abdominal tuberculosis is still a challenge due to its non-specific symptoms. Abdominal tuberculosis and ovarian cancer may show similar symptoms, laboratory and imaging features. The goal of our report is to emphasize for the need of a diagnostic approach based on clinical manifestations, laboratory, imaging findings, and additional tests for considering a diagnosis of abdominal tuberculosis rather than ovarian cancer.

Case presentation

We report 3 cases of abdominal tuberculosis in our Onco-gynaecology Division, Department of Obstetrics and Gynaecology, Sardjito Hospital, Yogyakarta, Indonesia in 2018 which were previously diagnosed as ovarian malignancy and managed surgically. All of our patients experienced abdominal pain and enlargement but only two of them had significant weight loss. The general symptoms were typically found in onco-gynaecology patients, especially in those with ovarian malignancy. Ultrasound examination showed multilocular masses, 2 of them with solid parts and ascites. Cancer antigen 125 (CA-125) levels were found increasing in those three patients. All of them were treated surgically and diagnosis of abdominal tuberculosis was established through the histopathological result of tissue biopsy. Based on our cases and literature, we consider the need of a diagnostic approach to differentiate abdominal tuberculosis from ovarian malignancy, an attempt to avoid unnecessary invasive procedures that put burden risk for the patients.

Conclusion

Minimally invasive tests to establish the diagnosis of abdominal tuberculosis should be optimized to reduce the burden risk of laparotomy. Careful diagnostic steps should be followed to avoid wrong diagnosis.

Tuberculous peritonitis mimicking carcinomatosis peritonei: CT findings and histopathologic correlation

The distinction between tuberculous peritonitis and peritoneal carcinomatosis is extremely difficult in patients with omental cake appearance on computed tomography and elevated CA-125 level. A 21-year-old female presented with abdominal distention, diarrhea, nausea, fever, weight loss, and night sweats. Serum CA-125 level was 563 U/L (normal range: <35 U/L) and other tumor markers were within normal range. Radiologic studies showed massive ascites, smooth minimal thickening and increased contrast enhancement of peritoneum, omental nodularities, hepatomegaly, and right pleural effusion. No underlying malignancy that could cause this condition was detected clinically and radiologically. Ultrasound-guided omental tru-cut biopsy was performed to exclude carcinomatosis peritonei. Histopathologic examination showed small-medium-sized granulomas with caseous necrosis. Molecular microbiology tests of biopsy specimens confirmed diagnosis of tuberculosis. In conclusion, tuberculous peritonitis should be in differential diagnosis of a patient with ascites, omental nodularities and elevated serum CA-125 levels.

Biliary Peritonitis due to a Ruptured Amebic Liver Abscess Mimicking a Periampullary Tumor and Liver Metastases with the Elevation of CA 19-9 and CA 125: A Case Report

Introduction

An amebic liver abscess is the most common presentation of extraintestinal amebiasis. This condition is the result of a parasite infection caused by Entamoeba histolytica.

Materials and Methods

We report a case of a 53-year-old male who presented with abdominal pain in the right upper quadrant, jaundice, and a 10-kg weight loss within a 1-month span.

Results and Conclusion

A wide range of symptoms and findings in the imaging tests suggestive of neoplasia, elevated levels of CA 19-9 and CA 125, and the presentation of biliary peritonitis as a complication makes this case a challenge for its approach and management.

Developing a deeper insight into reproductive biomarkers

The development of biomarkers of reproductive medicine is still in its infancy because many black boxes are still present in reproductive medicine. Novel approaches to human infertility diagnostics and treatment must be developed because reproductive medicine has lagged behind in the implementation of biomarkers in clinical medicine. Despite the dearth of the available literature, the current rapid pace of publications suggests that this gap will soon be filled therefore; this review is a précis of the research that has been done so far and will provide a basis for the development of biomarkers in reproductive medicine.

Screening for genital tuberculosis in a limited resource country: case report

BACKGROUND

Screening for benign or malignant process of pelvis in young females is a challenge for a physician in a limited resource country. Tuberculosis should be always considered in the differential diagnosis of a pelvic mass in countries with high prevalence of tuberculosis. Negative results of analysis of peritoneal fluid for acid-fast staining, late cultures, and unavailability of new diagnostics methods such as polymerase chain reaction and adenosine deaminase of the aspirated fluid from peritoneal cavity can often result in invasive diagnostic procedures such as laparotomy.

CASE PRESENTATION

We report a case of a 24 year old Albanian unemployed female living in urban place in Kosovo who presented with abdominal pain, loss of appetite, fever, headache, a weight loss, nonproductive cough and menstrual irregularity for three weeks. In this example case, the patient with cystic mass in tubo-ovarial complex and elevated serum cancer antigen 125 levels was diagnosed for genital tuberculosis after performing laparotomy. Caseose mass found in left tubo-ovarial complex and histopathological examination of biopsied tissue were the fastest diagnostic tools for confirming pelvis TB. The Lowenstein-Jensen cultures were positive after six weeks and her family history was positive for tuberculosis.

CONCLUSION

Young females with abdominopelvic mass, ascites, a positive family history for tuberculosis and high serum cancer antigen 125, should always raise suspicion of tuberculosis especially in a limited resource country. A laparoscopy combined with peritoneal biopsy should be performed to confirm the diagnosis as this could lead to a prevention of unnecessary laparotomies.

CT Differentiation of Female Peritoneal Tuberculosis and Peritoneal Carcinomatosis From Normal-Sized Ovarian Cancer

OBJECTIVE

The purpose of this study was to analyze the computed tomography (CT) features of female peritoneal tuberculosis and peritoneal carcinomatosis from normal-sized ovarian cancer for their differentiation.

MATERIALS AND METHODS

We analyzed the CT features of 18 female peritoneal tuberculosis and 17 peritoneal carcinomatosis with proven normal-sized ovarian carcinomas. Omental change, mesenteric change, parietal peritoneal thickening, lymph node enlargement, ascites, ovarian CT attenuation, and ovarian capsular change were analyzed.

RESULTS

Heterogeneous parenchymal hyperattenuation and capsular change of the ovary were more frequently seen in cases of peritoneal carcinomatosis than in cases of female peritoneal tuberculosis (P = 0.002, P < 0.001, respectively). There were no statistically significant differences in the other CT features.

CONCLUSIONS

The differentiation of female peritoneal tuberculosis and peritoneal carcinomatosis with normal-sized ovarian cancer by CT may be a diagnostic challenge. Ovarian hyperattenuation and any prominent ovarian capsular change may facilitate the differentiation between these groups.

Coexisting genital malignancies with tuberculosis: A case series with review of literature

Objective:

To study a case series of genital malignancies coexisting with genital tuberculosis.

Materials and Methods:

A series of three cases with known genital malignancies were found to have coexisting genital tuberculosis on subsequent workup.

Results:

First case was a 45 years old lady who underwent staging laparotomy for ovarian cancer. On histopathology examination, there was coexisting tuberculosis with papillary serous carcinoma. Second case was 53 years old postmenopausal lady who underwent extrafascial hysterectomy along with pelvic lymph node dissection. Histopathology showed tubercular changes along with endometrial malignancy. Third patient was a 50 years old postmenopausal lady with stage IIA carcinoma of cervix. She underwent radical hysterectomy and histopathology revealed tubercular changes in pelvic lymph nodes. All patients were given antitubercular therapy for 9 months in postoperative period along with adjuvant therapy.

Conclusion:

Although diagnosed as an incidental finding in the case series, genital tuberculosis may present in patients with malignancies as a result of immunosupression.

Role of Imaging in Peritoneal Surface Malignancies

Imaging plays a vital role in the evaluation of peritoneal malignancies. The presence of peritoneal metastases (PM) alters tumor staging, with direct implications in treatment choice and prognosis. Cytoreductive surgery (CRS) and Hyperthermic intraperitoneal chemotherapy (HIPEC) as a combined modality treatment have led to prolonged survival and even cure in selected patients with PM. Better outcomes are seen in patients with limited disease spread. Therefore, early diagnosis of peritoneal tumor seeding is essential. Despite significant advancement of technology, assessment of the origin of PM is often difficult, due partly to the complex peritoneal anatomy and partly due to the complex overlap of imaging features. Multidetector CT (MDCT) is the main stay due to its wide availbility, rapid evaluation, robust technique and good resolution. Imaging plays a vital role in selecting patients for the combined modality treatment. MRI is not as popular as CT due to limited availability, time required for the study and lack of experience with interpreting the results. PET-CT is useful in ruling out extra peritoneal disease and it is the CT component that is more reliable for predicting the disease extent. This article reviews the current use of various imaging modalities in various stages of treatment of patients with PM especially those undergoing CRS and HIPEC.

[Pseudo-tumoral peritoneal tuberculosis mimicking ovarian cancer: an important differential diagnosis to consider]

Peritoneal tuberculosis is a curable infectious disease that can simulate advanced ovarian cancer, leading to extensive and unnecessary surgical procedures commonly performed on women of reproductive age. We report a new case of pseudo-tumoral peritoneal tuberculosis in a 43-year old female patient with suspected ovarian cancer associated with peritoneal carcinomatosis. The diagnosis of peritoneal tuberculosis was based on exploratory laparotomy with extemporaneous histological examination. The patient responded well to anti-tuberculosis treatment according to 2ERHZ/4RH protocol.

Peritoneal tuberculosis with elevated CA-125 mimicking ovarian cancer with carcinomatosis peritonei: Crucial CT findings

Preoperative diagnosis of peritoneal tuberculosis is often difficult because of confusion with ovarian cancer. A 56-year-old woman was admitted to our hospital with abdominal fullness. Ascites, prominent bilateral ovaries, and elevated CA-125 were noted. Computed tomography showed thickened peritoneum and strandings in the mesentery and omentum. Exploratory laparotomy was performed under the provisional diagnosis of ovarian cancer, but the final diagnosis was peritoneal tuberculosis. Careful evaluation of bilateral fallopian tubes and ovaries and peritoneum are helpful for correct diagnosis.

MDCT of pelvic inflammatory disease: a review of the pathophysiology, gamut of imaging findings, and treatment

Representing an ascending, sexually spread pyogenic infection of the female genital tract, pelvic inflammatory disease (PID) is a commonly encountered cause for emergency visits and hospitalizations among young and adult female patients. Though gynecologic evaluation and sonography constitute the mainstay of diagnosis, multidetector CT imaging of the abdomen and pelvis is not uncommonly performed, often as the initial imaging modality, due to the frequently vague and indeterminate clinical presentation. As such, knowledge and attenuation to the often subtle early imaging features of PID afford the radiologist a critical chance to direct and expedite appropriate pathways of patient care, minimizing the risk for secondary complications, including infertility, ectopic pregnancy, and enteric adhesions. In this paper, we will review the pathophysiology, clinical presentation, early and late imaging features of PID as well as potential secondary complications and treatment options. Additionally, we will discuss published data metrics on CT performance regarding sensitivity and specificity for diagnosis as well as potential imaging differential diagnostic considerations.

Disseminated tuberculosis in a non immun compromised patient with a complicated diagnosis

Tuberculosis (TB) has become a global emergency worldwide. The long time period between the exposure to TB bacillus and the onset of symptoms cause a delay in diagnosis. Herein, we report a case of 64-year-old female patient suffering from dyspepsia, anorexia, weight loss and abdominal pain for the last 8 months. Physical examination, ascites fluid evaluation, chest radiography, ultrasonographic and tomographic scans, histopathological analysis of the lymphadenopathy (LAP) and endometrial tissue revealed TB. A fourfold antituberculous treatment with isoniazid, pyrazinamide, rifampicin and ethambutol was prescribed for two months and for four months maintenance therapy with isoniazid and rifampicin was given. On the fourth month of the medical treatment the patient clinically recovered. Since the diagnosis of TB is difficult, high grade suspicion, combination of the radiologic, microbiologic and histopathological examinations are needed to achieve a diagnosis.

Peritoneal carcinomatosis mimicking a peritoneal tuberculosis

Symptoms of a peritoneal progression from ovarian cancer are nonspecific such as abdominal pain, abdominal distention and more. Many imaging studies and serum CA-125 help diagnosis. However, it is difficult to exclude the instances of the diffuse peritoneal diseases that mimic carcinomatosis. The elevated CA-125 level usually correlates with the peritoneal carcimatosis, but it is often found in other peritoneal diseases. Therefore, the pathologic confirmation is necessary because of other mimicking diseases. In our case, CA-125 levels were elevated. Abdominal computed tomography finding was suspected a peritoneal tuberculosis but the pathologic result was the peritoneal carcimatosis, eventually.

Fatal Disseminated Tuberculous Peritonitis following Spontaneous Abortion: A Case Report

We describe a rare case of fatal disseminated tuberculous peritonitis in a young woman with rapid progressive clinical course following spontaneous abortion of 20-week gestation. Clinical and laboratory findings were initially unremarkable. She underwent diagnostic laparoscopy which revealed numerous tiny implants on the peritoneum and viscera. Histopathology showed chronic caseating granulomas, and the tissue culture grew Mycobacterium tuberculosis. At fifth day of the antituberculous treatment multiorgan failure occurred in terms of pulmonary, hepatic, and renal insufficiency. She developed refractory metabolic acidosis with coagulopathy and pancytopenia, and she died of acute respiratory distress syndrome and septic shock on her twelfth day of hospitalization.

Disseminated peritoneal tuberculosis mimicking advanced ovarian cancer

The objective was to evaluate the clinical and radiological features of peritoneal tuberculosis (PTB) that resembled advanced ovarian malignancy. A retrospective review of all patients diagnosed with PTB over a period of 10 years was made. The data included: age, presenting symptom(s), CA125 level, microbiological, histological and cytological studies of the surgical specimens. The radiological and operative findings were also reviewed. A total of 16 patients were identified. The median age was 29.5 years (range 13-65 years). The median CA125 level was 319 U/ml (range 45-1,072 U/ml). The most common symptoms were abdominal distention and pain in 13 patients. Imaging studies showed ascites in all patients. Six patients had laparotomy and 10 had laparoscopy procedure. All patients received anti-tuberculosis treatment and had complete cure. A high index of suspicion of PTB is important to avoid unnecessary extended surgery in relatively young patients with nonspecific clinical features.

Clinical significance of serum CA-125 in Korean females with ascites

PURPOSE

Mycobacterium tuberculosis is endemic in Korea. Because tuberculous peritonitis is characterized by ascites, abdominal pain, abdominal mass and elevation of serum CA-125, it can be confused with ovarian malignancies. The aim of this study was to evaluate the significance of serum CA-125 level in the differential diagnosis of tuberculous peritonitis and ovarian malignancy in a Mycobacterium tuberculosis-endemic area.

MATERIALS AND METHODS

The medical records of patients diagnosed with tuberculous peritonitis (n=48) or epithelial ovarian malignancy (n=370) at Samsung Medical Center from January 2000 to October 2009 were retrospectively reviewed.

RESULTS

Median serum CA-125 level in the epithelial ovarian cancer group was significantly higher than that in the tuberculous peritonitis group (p ≤ 0.01). Only one patient (2.1%) in the tuberculous peritonitis group had a serum CA-125 level over 2000 U/mL. However, 109 patients (29.5%) in the epithelial ovarian cancer group had a serum CA-125 level over 2000 U/mL. At the CA-125 ranges of 400 to 599 and 600 to 799, the proportions of those with tuberculous peritonitis were 24% and 21.9%, respectively. At a serum CA-125 level over 1000 U/mL, however, the proportion of tuberculous peritonitis was much lower (2.1%).

CONCLUSION

Tuberculous peritonitis should be considered in the evaluation of female patients with ascites and high serum CA-125.

Ovarian carcinoma or abdominal tuberculosis?-A diagnostic dilemma: study of fifteen cases

OBJECTIVE

To evaluate the clinical, laboratory, and diagnostic features in women with abdominal tuberculosis that resembled advanced ovarian malignancy.

METHODS

A retrospective review of women with abdominal tuberculosis who were managed at GCRI Ahmedabad from 1996 to 2001 was undertaken.

RESULTS

Fifteen patients (3.06 %) with suspected ovarian cancer cases, finally diagnosed as abdominal tuberculosis over a 6-year period (1996-2001), are analyzed. During this period, 492 patients were operated for suspected ovarian malignancy. Pre-operatively, ultrasound-guided biopsies were inconclusive in 14 cases and hence, exploratory laparotomy was planned. They underwent laparotomy and biopsy for final diagnosis. Frozen sections-of peritoneal/omental biopsies in 11 cases and ovarian tumour in three cases-were indicative of tuberculosis in all the 14 cases.

CONCLUSION

The data of this study indicate that the majority of the cases with peritoneal tuberculosis can be diagnosed intra-operatively through the use of frozen section in conjunction with clinical features. Ascites and high levels of Ca125 do not necessarily indicate that the clinical picture is malignant in reproductive women. Laparoscopic tissue biopsy may be a fundamental tool in the management of such cases to avoid extended surgery.

Conservative management of a high output enterocutaneous fistula in abdominal tuberculosis

A 25-year-old lady with a high-output, tuberculous, entero-cutaneous fistula was managed successfully by conservative means in a teaching hospital in Nairobi, Kenya.

Current concepts in the management of tuberculosis

Tuberculosis (TB) poses a serious threat to public health throughout the world but disproportionately afflicts low-income nations. Persons in close contact with a patient with active pulmonary TB and those from endemic regions of the world are at highest risk of primary infection, whereas patients with compromised immune systems are at highest risk of reactivation of latent TB infection (LTBI). Tuberculosis can affect any organ system. Clinical manifestations vary accordingly but often include fever, night sweats, and weight loss. Positive results on either a tuberculin skin test or an interferon-γ release assay in the absence of active TB establish a diagnosis of LTBI. A combination of epidemiological, clinical, radiographic, microbiological, and histopathologic features is used to establish the diagnosis of active TB. Patients with suspected active pulmonary TB should submit 3 sputum specimens for acid-fast bacilli smears and culture, with nucleic acid amplification testing performed on at least 1 specimen. For patients with LTBI, treatment with isoniazid for 9 months is preferred. Patients with active TB should be treated with multiple agents to achieve bacterial clearance, to reduce the risk of transmission, and to prevent the emergence of drug resistance. Directly observed therapy is recommended for the treatment of active TB. Health care professionals should collaborate, when possible, with local and state public health departments to care for patients with TB. Patients with drug-resistant TB or coinfection with human immunodeficiency virus should be treated in collaboration with TB specialists. Public health measures to prevent the spread of TB include appropriate respiratory isolation of patients with active pulmonary TB, contact investigation, and reduction of the LTBI burden.

Peritoneal tuberculosis

The peritoneum is one of the locations outside the most common pulmonary tuberculosis. Peritoneal tuberculosis poses a public health problem in endemic regions of the world. The phenomenon of migration, the increased use of immunosuppressive therapy and the epidemic of AIDS have contributed to a resurgence of this disease in regions where it was previously controlled. The aim of this review is to expose the clinical, biologic end radiologic futures of the peritoneal tuberculosis and to present the methods of diagnosis and treatment. The diagnosis of this disease is difficult and still remains a challenge because of its insidious nature, the variability of presentation and limitations of available diagnostic tests. The disease usually presents a picture of lymphocytic exudative ascites. There are many complementary tests with variable sensitivities and specificities to confirm the diagnosis of peritoneal tuberculosis. Isolation of mycobacteria by culture of ascitic fluid or histological examination of peritoneal biopsy ideally performed by laparoscopy remains the investigation of choice. The role of PCR, ascitic adenosine deaminase, interferon gamma and the radiometric BACTEC system can improve the diagnostic yield. An antituberculous treatment with group 1 of the WHO for 6 months is sufficient in most cases.

Extraovarian conditions mimicking ovarian cancer: a single center experience of 15 years

OBJECTIVE

This study aims to review cases of extra-ovarian conditions that resembled ovarian malignancy and thus, to evaluate the distribution of primary pathology mimicking ovarian malignancy.

METHODS

A retrospective review of women, with final pathology of extra-ovarian diseases mimicking ovarian malignancy, which were managed at Zekai Tahir Burak Women's Health Education and Research Hospital, from January 1995 to April 2010 was undertaken.

RESULTS

Among the 2,210 women treated during the study period, extra-ovarian diseases accounted for 5.11% (113/2,210) of all the cases. Of the 113 extra-ovarian diseases, 42 (37.17%) were peritoneal tuberculosis, 25 (22.13%) were gastrointestinal malignancies, 20 (17.70%) were pelvic abscess, 8 (7.08%) were pelvic echinococcosis, 8 (7.08) were schwannoma and other retroperitoneal tumors, 4 (3.53%) were malignant lymphoma, 2 (1.77%) were chronic ectopic pregnancy, gossypiboma, and mesenteric cyst, respectively.

CONCLUSION

Medical awareness of infectious diseases such as peritoneal tuberculosis, pelvic abscess, and pelvic echinococcosis in the differential diagnosis of ovarian malignancy is still lacking, especially in developing countries. In addition, in case of a pelvic mass, gastrointestinal and retroperitoneal tumors and malignant lymphoma should always be considered to avoid pitfalls in diagnosis and therapy.

Tuberculosis and malignancy

BACKGROUND

Tuberculosis (TB) and malignancy represent global threats claiming millions of lives and inflicting formidable suffering worldwide. Surprisingly, the pathophysiological and practical implications of their co-existence have received little attention.

METHODS

Therefore, we sought to review the available literature on the field and identify data regarding the association between TB and malignancy in order to highlight the neglected aspects of this association and probably derive clinically useful information. We searched PubMed up to June 2008 for case reports, case series, non-comparative and comparative studies that were written in English and reported data on the occurrence of both TB infection and a neoplastic disorder in the same patient(s). The development of mycobacterial infections in patients with immunocompromized conditions is well known and was considered outside the scope of this review.

EVIDENCE SYNTHESIS

The synthesis of the available evidence enabled us to establish three different types of association between malignancy and TB: (i) the development of cancer on the background of a previous tuberculous infection; (ii) the concurrent existence of TB and malignancy in the same patient(s) or clinical specimen(s); and (iii) the diagnostic challenges arising from the multi-faceted presentations of these two disorders.

CONCLUSION

We conclude that clinicians need to be aware of the protean manifestations of TB and cancer and maintain a high index of suspicion for simultaneous and/or misleading presentations. In addition, further research is required to determine if a tuberculous infection, being similar to other chronic infections and inflammatory conditions, may facilitate carcinogenesis.

CA125 in ovarian cancer

A quarter of a century since its discovery, circulating CA125 antigen is recommended for clinical use in the USA for ovarian cancer screening of high-risk women with ovaries, despite its limited sensitivity and specificity. Recent findings suggest that CA125 might also serve as a predictive marker for pre-invasive ovarian carcinoma. Methods to quantify circulating CA125 evolved toward sensitive and reliable double-determinant ELISA assays. The CA125 gene, MUC16, was cloned 20 years after the protein discovery and revealed a very complex and unusual glycoprotein structure, suggesting an immunological role. Recent evidence points toward CA125 function in the induction of materno-fetal tolerance through the alteration of natural killer phenotype. Two receptors for CA125 have been described: mesothelin and galectin-1. The specific location and functional proprieties of CA125 make it a therapeutic target of choice; clinical trials have demonstrated that anti-CA125 injections are well tolerated and suggest a potential survival benefit.

Diagnosis of patients with peritoneal diseases: an analysis of 42 cases

AIM: To evaluate the clinical value of different methods for diagnosis of peritoneal diseases.

METHODS: A total of 42 patients with peritoneal diseases were included in the study. Measurement of serum tumor markers and computed tomography (CT) were performed in all patients, peritoneocentesis in 40 patients, positron emission tomography (PET)/CT in 9 patients, and ultrasound-guided percutaneous peritoneal biopsy in 13 patients. The sensitivity, specificity and accuracy of each method and the causes of peritoneal diseases were analyzed.

RESULTS: The sensitivity of measurement of serum tumor markers (CEA, CA153, CA19-9, CA242 and CA125) in the diagnosis of metastatic peritoneal tumors was 14.8%, 18.5%, 29.6%, 22.2% and 100%, and the specificity was 80.0%, 93.3%, 93.3%, 93.3% and 0%, respectively. The sensitivity and specificity of exfoliative cytologic examination in the diagnosis of carcinous ascites were 36% and 100%, respectively. The sensitivity and specificity of ascites adenosine deaminase (ADA) in the diagnosis of tuberculous ascites were 92.3% and 92.5%, respectively. The accuracy of CT, PET/CE and percutaneous peritoneal biopsy was 19%, 78% and 85%, respectively.

CONCLUSION: Serum tumor marker measurement, exfoliative cytologic examination and ascites ADA can help differentiate between carcinous and inflammatory peritoneal diseases. The accuracy of PET/CT and percutaneous peritoneal biopsy is higher than that of CT.

Familial tuberculosis mimicking advanced ovarian cancer

Genital TB may present as on abdominopelvic mass mimicking ovarian malignancy because clinical and laboratory findings are similar. Family history is very important and should be considered for differential diagnosis. Three cases of genital TB with presentation of abdominopelvic masses and with no signs and symptoms of TB were presented. Two of them had positive family history of pulmonary TB. Tissue diagnosis was the best method for diagnosis of genital TB, but it should be reminded that if positive family history of TB was present, mini laparotomy should be done to take biopsy and to make rapid diagnosis before treatment.

Peritoneal tuberculosis in premenopausal patients with elevated serum CA 125

INTRODUCTION

Peritoneal tuberculosis predominantly involves the omentum, intestinal tract, liver, spleen, and genitourinary tract and occurs in 1-4% of patients with pulmonary tuberculosis. Peritoneal tuberculosis may mimic a pelvic mass in imaging studies and also may increase CA-125 levels. Peritoneal tuberculosis may also produce massive ascites, and intraperitoneal gross appearance might be similar to the peritoneal carcinomatosis. Therefore, peritoneal tuberculosis is often confused with advanced-stage epithelial carcinoma because of similar clinical, radiologic, and laboratory findings and later intraoperative findings.

MATERIALS AND METHODS

The pathology records between January 2000 and August 2008 were retrospectively reviewed at 19 Mayis University Hospital. Twenty-two patients were found to have peritoneal caseating necrosis. A total of 13 out of 22 patients were found to have high CA 125 level.

RESULTS

Among these 13 patients, 8 patients received/are receiving anti-tuberculous therapy after they were incidentally diagnosed with peritoneal tuberculosis.

CONCLUSION

Increased CA 125 levels should be evaluated carefully prior to aggressive surgical approach, especially in premenopausal women and frozen section evaluation should be done before extensive surgical procedure if there is any suspicion.

Clinical review of 23 patients with tuberculous peritonitis: presenting features and diagnosis

OBJECTIVE

To better identify which clinical, laboratory, radiological and invasive procedures were most useful in diagnosing tuberculous peritonitis and to assess the methods in order to reach the diagnosis in future cases.

METHODS

Tuberculous peritonitis cases diagnosed between 2000 and 2006 were reviewed retrospectively. Their clinical presentation, physical examination, laboratory and diagnostic methods were evaluated.

RESULTS

Twenty-three cases oftuberculous peritonitis were diagnosed. The mean age of the patients were 30 +/- 11 years and 16 were women. The mean duration of symptoms prior to diagnosis was 3.6 months. All patients presented with abdominal pain. Abdominal swelling (91.3%), loss of appetite (87%) and weight loss (82.6%) were the other commonest symptoms. The major physical findings were ascites (78.3%) and fever (60.9%). The serum ascites albumin gradient was < 1.1 g/dL in all. An ascites fast bacilli smear was positive in 12 (52.2%) patients. Skin tests with purified protein derivative, adenosine deaminase and polymerase chain reaction were performed in seven, four and five patients, respectively. The tuberculous culture was positive in only two. The most common radiological findings were ascites (100%) and omental involvement (65.2%). A laparoscopy was performed in nine of 23 patients. A total of 22 patients completed anti-tuberculous therapy successfully and were cured, except one with cirrhosis.

CONCLUSION

Tuberculous peritonitis may be fatal but is medically cured if diagnosed in a timely fashion. Although both non-invasive and invasive tests have additional benefits, clinician suspicion is still the first step for the diagnosis of tuberculous peritonitis.