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 Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 3  |  Issue : 1  |  Page : 14-16

Ovarian tubercular abscess mimicking ovarian carcinoma: A rare case report


1 Department of Chest, Medinipore Medical College, Medinipur, West Bengal, India
2 Department of Chest, Medinipore Medical College and Hospital, Medinipur, West Bengal, India
3 Department of Chest, National Medical College and Hospital, West Bengal, India

Date of Web Publication12-Dec-2014

Correspondence Address:
Abinash Agarwala
D1/5, Dakhini Housing Estate, Akra Dutta Bagan, Kolkata - 700 018, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2320-8775.146844

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  Abstract 

Although genito-urinary tuberculosis is common, reports of isolated ovarian tubercular abscess are rare. Ovarian tubercular abscess may mimics that of an ovarian tumor, leading to diagnostic difficulties. We reported a case report of 35 years woman presented with chronic pain abdomen, weight loss, low-grade fever and a right ovarian mass on ultrasound, with a significantly elevated CA-125 level. On clinical and radiological evidence, diagnosis of ovarian carcinoma was made, and laparotomy was performed with resection of the ovary. Postoperative specimen sent for histological examination that revealed classic epithelioid granuloma and acid-fast bacilli were present in Ziehl-Neelsen stain. Patient was put on antitubercular regimen from our Dots center. She is improving clinical after taking antitubercular drug and is on regular follow up at our chest outpatient department. Ovarian tubercular abscess is common in young women living in endemic zones, but case report of isolated tubercular abscess is rarely reported. CA-125 can be raised in both ovarian tubercular abscess and ovarian carcinoma, and only imaging is not always conclusive. Laparotomy followed by tissue diagnosis can be helpful in this situation. As the prognosis and treatment outcome of ovarian tubercular abscess and ovarian carcinoma is different, proper diagnosis by laparotomy should be done. Early diagnosis of ovarian tubercular abscess is vital as untreated disease can lead to infertility.

Keywords: Genito-urinary tuberculosis, ovarian carcinoma CA-125, ovarian tubercular abscess


How to cite this article:
Agarwala A, Dhua A, Shamim S, Roy P P. Ovarian tubercular abscess mimicking ovarian carcinoma: A rare case report . J Assoc Chest Physicians 2015;3:14-6

How to cite this URL:
Agarwala A, Dhua A, Shamim S, Roy P P. Ovarian tubercular abscess mimicking ovarian carcinoma: A rare case report . J Assoc Chest Physicians [serial online] 2015 [cited 2018 Dec 16];3:14-6. Available from: http://www.jacpjournal.org/text.asp?2015/3/1/14/146844


  Introdction Top


Genito-urinary tuberculosis (TB) is rare in developed countries, but in developing countries, we often reported cases of genito-urinary TB. However, it is difficult to estimate the true incidence because most patients are asymptomatic. The  Fallopian tube More Detailss are the most commonly involved female genital organ, and the disease is, usually, bilateral. Caseating granulomas can be identified on microscopic examination after endometrial biopsy or curettage. Occasionally patients can develop a tub ovarian abscess, which can also reveal granulomas and possibly bacilli on staining. But isolated ovarian tubercular abscess is rarely reported. So, we reported this case as it mimics ovarian carcinoma clinically and radiologically.


  Case report Top


A 35-year-old woman presented to our hospital with a 6 weeks history of pain abdomen. This was associated with a low-grade fever, weakness and anorexia. She also reported a weight loss and her body mass index was just 15. There was no history of contact with TB. Her menstruation history was normal. On vaginal examination, a left lateral, tender uterine mass was revealed. Blood examination showed mild anemia with a hemoglobin of 11 g/dL and an erythrocyte sedimentation rate of 86 mm. Her tumor markers were measured, and the level of CA-125 was 550 units/mL. HIV serology was negative. Chest X-ray was normal [Figure 1] and pelvic ultrasound demonstrated a heterogeneous left adnexal mass of 9.9 × 9.0 × 6.9 [Figure 2]. The initial diagnosis of ovarian carcinoma was made, and we proceeded to laparotomy. Postoperative specimen revealed a discrete cystic mass of the right ovary. The rest of the peritoneal cavity was completely unremarkable. Computed tomography scan of the abdomen was done for postoperative evaluation, which shows small residual collection [Figure 3]. Histopathological examination of the specimen showed giant cell proliferation with central caseous necrosis along with acid-fast bacilli present on Ziehl-Neelsen stain. There was no sign of malignancy, and the diagnosis was revised to ovarian tubercular abscess. Patient was put on antitubercular treatment. Recovery was marked by complete resolution of the pelvic pain, a weight gain and a decrease in the CA-125 level.
Figure 1: Chest X-ray was normal

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Figure 2: Pelvic ultrasound demonstrated a heterogeneous left adnexal mass

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Figure 3: Postoperative computed tomography scan of abdomen shows small residual collection

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  Discussion Top


Ovarian abscess develops as an isolated phenomenon without simultaneous tubal infection is unusual but when it does occur, it is a result of blood or lymph-borne infection or direct implantation of infection into the ovary. The infection is within the substance of the ovary from the onset, when compared with that of a tubo-ovarian abscess, where the initial infection is confined to the superficial portion of the ovary. The initial symptom of the infection is abdominal pain, which may vary from a relatively mild cramp to a persistent aching pain. The pain may increase in severity until it either becomes intolerable or terminates in an acute episode associated with rupture. As the pain is due to the abscess expanding within the ovary, it is evident that the severity of the symptoms and the rapidity with which they progress are determined by the virulence of the infection. The definitive diagnosis of ovarian abscess being made only by laparotomy. In general, antibiotics alone will have little effect on the course of an ovarian abscess, and therefore surgical intervention may be indicated in the following circumstances.

Genito-urinary TB is the second most frequent location for extra-pulmonary TB. [1] It can represent up to 19% of gynecological admissions in some developing country. [2] The endometrial and fallopian tubes are almost always affected by the disease. The ovaries were involved in 62.5% of cases in one study. However, isolated ovarian TB with no other organ involvement is rarely reported in the literature. It classically affects young women aged 20-30 years who are living in endemic zones that mimic ovarian carcinoma - a diagnostic dilemma to a physician. Ca-125 is an antigenic determinant which is expressed in most nonmucinous epithelial ovarian carcinomas, and is raised in >80% of cases. [3],[4] It is very useful in postmenopausal women, where the positive predictive value for malignancy is nearly 95%. However, in premenopausal women, it can be elevated by benign conditions such as endometriosis, fibroids, and pelvic inflammatory disease, and indeed TB. [5],[6] In the case of ovarian TB, its level rarely rises above 500 U/ml, [4],[7] and decrease levels of CA-125 correlate with the resolution of the disease on antituberculous treatment. They suggest that serial measurements should be used to determine treatment efficacy. Imaging has low specificity, with both an ovarian malignancy and a tuberculous ovarian abscess Lantheaume et al. 2003. [7] Both can be heterogeneous masses, which can infiltrate omentum and neighboring organs. Ultrasound-guided transvaginal or transabdomenal biopsies may be used for preoperative diagnosis. Laparoscopy has been a great advance as it allows the diagnosis of TB in >97% of cases while avoiding the laparotomy. [8],[9] Nevertheless, in cases with high suspicion of malignancy, laparotomy is often the first choice to avoid tumor seeding along port tracts. However, even at open operation, it may be difficult to distinguish between the two diagnoses as the macroscopic appearance of pelvic TB can be similar to the carcinomatosis of extra ovarian carcinoma. [3]


  Conclusion Top


Isolated ovarian TB is rare. Its presentation can mimic that of an ovarian malignancy, with the rise in CA-125 level. Therefore, we should keep in mind as a differential diagnosis while treating the patients. Ovarian tubercular abscess can completely cured with proper dosing of antitubercular drugs and early diagnosis and treatment can prevent infertility in woman so while diagnosing ovarian carcinoma in woman of childbearing age we should think of ovarian tubercular abscess too.

 
  References Top

1.
Watfa J, Michel F. Uro-genital tuberculosis. Prog Urol 2005;15:602-3.  Back to cited text no. 1
    
2.
Agarwal J, Gupta JK. Female genital tuberculosis - a retrospective clinico-pathologic study of 501 cases. Indian J Pathol Microbiol 1993;36:389-97.  Back to cited text no. 2
    
3.
Straughn JM, Robertson MW, Partridge EE. A patient presenting with a pelvic mass, elevated CA-125, and fever. Gynecol Oncol 2000;77:471-2.  Back to cited text no. 3
    
4.
Simsek H, Savas MC, Kadayifci A, Tatar G. Elevated serum CA 125 concentration in patients with tuberculous peritonitis: A case-control study. Am J Gastroenterol 1997;92:1174-6.  Back to cited text no. 4
    
5.
Jana N, Mukhopadhyay S, Dhali GK. Pelvic tuberculosis with elevated serum CA125: A diagnostic dilemma. J Obstet Gynaecol 2007;27:217-8.  Back to cited text no. 5
    
6.
Pesut D, Stojsic J. Female genital tuberculosis - a disease seen again in Europe. Vojnosanit Pregl 2007;64:855-8.  Back to cited text no. 6
    
7.
Lantheaume S, Soler S, Issartel B, Isch JF, Lacassin F, Rougier Y, et al. Peritoneal tuberculosis simulating advanced ovarian carcinoma: A case report. Gynecol Obstet Fertil 2003;31:624-6.  Back to cited text no. 7
    
8.
Caspi B, Wolach V, von der Walde J, Weiss Y, Appelman Z, Hagay Z. Diagnosis of abdominal tuberculosis by transabdominal ultrasound-guided needle biopsy. Ultrasound Obstet Gynecol 2000;16:569-70.  Back to cited text no. 8
    
9.
Falk V, Ludviksson K, Agren G. Genital tuberculosis in women. Analysis of 187 newly diagnosed cases from 47 Swedish hospitals during the ten-year period 1968 to 1977. Am J Obstet Gynecol 1980;138:974-7.  Back to cited text no. 9
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