A 54-year-old postmenopausal African American female, G4P3013, with a past medical history of type 2 diabetes mellitus, hypertension, hypothyroidism, and stage 5 chronic kidney disease with multiple hospitalizations for hypercalcemia as well as recurrent pleural effusions, with a history of omental carcinomatosis of unknown origin, was referred to the gynecology-oncology service at a local community hospital following a laparoscopic incarcerated hernia repair where multiple abdominal lesions suspicious of ovarian carcinomatosis were visualized. The lesions were noted throughout the abdomen including the abdominal wall, bowel, liver, and pelvis. Biopsies of the lesions taken from the omentum and abdominal wall were found to be granulomatous with chronic inflammation and multinucleated giant cells. Some granulomas were matted, and others showed foreign bodies containing crystalloid material and rare granulomatous necrosis. Periodic acid-Schiff stain and acid fast bacilli stain were negative. Although cytology did not suggest neoplasm, the patient was immediately referred to the gynecology-oncology clinic due to the suspicion of an ovarian neoplasm.
On presentation to gynecology-oncology clinic, the patient offered no gynecological complaints but endorsed nonspecific symptoms. She complained of anorexia and accompanied weight loss. Hospital records confirmed a fifty-nine-pound weight loss over seven months. She also complained of a chronic cough with scant-sputum production. She denied abdominal pain, abdominal cramping, vaginal bleeding, abdominal bloating, nausea, vomiting, and constipation. On exam, the patient was noted to have abdominal ascites, and her CA-125 level was elevated at 57.4 U/ml, which had risen from 39.9 U/ml a month prior. Following the appointment, she was scheduled for a diagnostic laparoscopy with possible hysterectomy and bilateral salpingo-oophorectomy; however, surgery was delayed due to her being hospitalized for symptomatic hypercalcemia and recurrent pleural effusions.
Once the patient was stabilized, she was taken to the operating room for diagnostic laparoscopy. Intra-abdominal survey revealed white tubercle-like lesions that were consistent with peritoneal tuberculosis. Laparoscopic scissors were used to excise a piece of the peritoneal wall containing the tubercle-like lesions. The tissue was then sent to pathology.
The omental biopsy was originally reported as adipose tissue showing focal fibrosis, focal mild acute inflammation, few cyst formation, and multiple granulomatous chronic inflammation, with multinucleated giant cells. Periodic acid-Schiff stain and acid fast bacilli stain were negative, and a diagnosis of peritoneal tuberculosis was made. The patient was immediately started on rifampin, isoniazid, pyrazinamide, ethambutol (RIPE) therapy, supplemented with azithromycin and vitamin B6.
After several weeks of RIPE therapy, the patient was not showing any signs or improvement. Adenosine deaminase level was tested in the patients' pleural fluid and found to be elevated at 28.7 U/l. She also had a quantiferon test performed which was indeterminate. Decision was made to have the pathology from the tissue sample taken during surgery reviewed. The pathology revealed nonnecrotizing granulomatous inflammation (Figures 1(a) and 1(b)) and multinucleated giant cells (Figures 2 and 3(b)) consistent with sarcoidosis. The patient was immediately referred to the department of pulmonology and rheumatology, at which point she was started on corticosteroids and had an improvement in her condition.