A nulliparous woman, aged 17 years, presented to hospital with a 2 month-history of pelvic pain. This was associated with a low-grade fever, weakness, and anorexia. She also reported a weight loss of 4kg in 6 months, with a BMI of just 15. She had received the Bacille Calmette-Guerin (BCG) vaccination at birth and there was no history of contact with tuberculosis.
Menarche was at age 12, with regular cycles, however her last menstrual period was over four months ago. Vaginal examination revealed a right lateral uterine mass tender to palpation. Blood tests showed a moderate anaemia with a haemoglobin of 10g/dL, and an erythrocyte sedimentation rate of 90mm. Tumour markers were measured, and the level of CA-125 was 450 units/mL (15 times the upper limit). HIV serology was negative.
Plain radiography of chest and abdomen was normal. Pelvic ultrasound demonstrated a heterogenous right adnexal mass of 50 x 45mm and a small amount of ascites in the sac of Douglas. The initial diagnosis was ovarian carcinoma, and we proceeded to laparotomy. This revealed a discrete cystic mass of the right ovary which was fully excised (Figure 1). The rest of the peritoneal cavity was completely unremarkable.
Postoperative histopathological examination showed giant cell proliferation with central caseous necrosis (Figure 2). There was no sign of malignancy, and the diagnosis was revised to ovarian tuberculosis. No other focus of TB was found, including pulmonary and urinary disease. Antituberculosis treatment was commenced, and continued for eight months as per current guidelines in Madagascar. Recovery was marked by complete resolution of the pelvic pain, a weight gain of 2 kg in 2 months, normalisation of her menstrual cycles, and a decrease in the CA-125 level.