A 46-year-old female patient with a P2L2 medical history visited our emergency department due to gradual onset of abdominal pain, which was progressively worsening with time. It was more on the right lower quadrant. Movement and touch exacerbated the pain, while rest provided relief. In addition, the patient had experienced symmetrical abdominal distension for over a month, which was accompanied by early feelings of fullness, nausea, diarrhea, and alternating constipation. No incidents of vomiting, heartburn, yellow discoloration, or swelling in the lower limbs were reported. The patient also reported no respiratory symptoms, such as difficulty breathing or coughing. She denied history of contact TB. Vital signs were measured as follows: temperature of 36.7 C, blood pressure of 116/76 mmHg, pulse rate of 90 beats per minute, respiratory rate of 18 breaths per minute, and oxygen saturation of 99% on room air.
On physical examination, the abdomen was distended with normal contour and a small scar in the lower quadrant; normal bowel sounds were heard upon auscultation. Tenderness was noted in the right iliac fossa region, but there were no palpable masses. Both external and internal genitalia were normal upon examination, with a healthy cervix observed. Other systems were unremarkable. The laboratory results showed leukocytosis with a count of 14.5 (4-11) and a predominant 76% of neutrophils, as well as a low hemoglobin level of 10.6 (11.5-16.5). The CA-125 level was elevated to 52.5 (normal range: 0-35 units per mL). The renal and liver function tests, including urea and creatinine levels, were normal. Inflammatory marker C-reactive protein test was high 800 (0.8-3 mg/L). A chest X-ray showed normal results, while the abdominal ultrasound revealed the presence of massive ascites, a suspicious heterogeneous mass in the posterior aspect of the uterus, and mesenteric lymphadenopathies. The findings led to the impression of an ovarian mass and a clinical diagnosis of ovarian cancer. However, due to financial constraints, a computed tomography (CT) scan was not conducted, and no biopsy was performed prior to surgery.
Intra-operatively, no obvious ovarian tumor was encountered instead; disseminated creamy white patches on the uterus and left adnexa were seen. About 4500-mL straw-colored ascitic fluid and disseminated creamy white patches on the bowels and omentum were evident giving an impression of carcinomatosis. Therefore, diagnosis of ovarian cancer was entertained. The liver and right ovary were essentially unremarkable. Total hysterectomy and partial omentectomy were done, and the specimens were submitted for histopathology analysis. Peritoneal fluid was submitted for cytological analysis and for GeneXpert for the TB. While the GeneXpert results were negative, the histopathological studies of the ovary, endometrium, and fallopian tube revealed numerous caseating granulomatous inflammation with Langhans-type multinucleated giant cells (Figure 1). Similar findings were observed on the omental tissue. Ziehl-Neelsen staining confirmed the presence of acid-fast bacilli (AFB) (Figure 2). Therefore, the final diagnosis of FG-TB was established. The patient was kept on anti-TB rifampicin/isoniazid/pyrizinaamide/efavirenz as well as ceftriaxone and antipain medications. She did well immediately after surgery and was discharged on day 5. The patient completely recovered during the 6 months of close follow-up visits and had resumed her daily activities.