A 52-year-old postmenopausal female of Filipino origin presented to hospital with a three-day history of increasing abdominal bloating, vomiting, and fevers. She denied urinary or bowel symptoms. This patient had no significant past medical or family history and was a nonsmoker. She moved to Australia from the Philippines in 2015 and worked as a nurse in both countries.
On admission, she had a temperature of 39.9 C, a heart rate of 127, and a respiratory rate of 35. Her abdomen was markedly distended. There was a palpable tender mass in the right lower quadrant, with guarding and rebound tenderness.
Initial investigations showed mildly deranged liver enzymes, an elevated CRP, and slightly elevated CA-125 and CA-19.9 (Table 1). CT scan showed a 22 x 13 cm multiseptated cystic lesion almost certainly of ovarian aetiology, as well as omental fat hazing, raising the possibility of an acute omental infarction (Figures 1(a) and 1(b)).
She was admitted for observation and intravenous antibiotics. Her fever resolved, and she was discharged home with a plan to follow-up in outpatient clinic for elective ovarian cystectomy.
Ten days later, the patient re-presented to hospital with severe abdominal pain and ongoing fevers. Repeat laboratory results showed worsening liver enzymes and a further rise of CRP (Table 1). A repeat CT scan showed the large ovarian cyst had likely ruptured with new generalised ascites and peritoneal enhancement, concerning for disseminated disease (Figures 2(a) and 2(b)).
The patient underwent emergency laparotomy with total abdominal hysterectomy, bilateral salpingo-oophorectomy, infracolic omentectomy, and appendectomy. The cyst had a small leak, and 3.5 L of fluid was drained from the cyst and sent for histology (Figure 3(a)). A further 200 ml of ascitic fluid was collected. Inflammatory changes on the surface of the pelvis, and multiple inflammatory deposits overlying small bowel mesentery were noted (Figure 3(b)). Histology of the cyst showed a benign mucinous cystadenoma. The uterus, ovarian cyst, omentum, and appendix contained florid granulomatous inflammation and caseous necrosis. Peritoneal fluid cultured Mycobacterium tuberculosis. A chest CT confirmed lymph node calcification consistent with previous tuberculosis, with no evidence of active infection. Her postoperative recovery was uneventful, and she was commenced on isoniazid, rifampicin, ethambutol, and pyrazinamide under guidance of the Infectious Disease team. The patient remained well at a recent 3-month follow-up.