A sixty-four year old multipar female was admitted to our outpatient clinic with fatigue, abdominal distension, anorexia, hot flushes, and weight loss of 8 kg within eight months. She was hypertensive for a decade but did not report any important disease in her family history. She had no known exposure to TB, never smoked, and never used alcohol. During her physical examination the patient was conscious, cooperative, and showed normal vital signs. The conjunctiva was pale. The examination of the systems was normal except ascites and lymphadenopathies (LAPs). No stigmata of chronic liver disease were found. Multiple painless, mobile, and solid LAPs were found, the biggest being 2 cm in the left cervical and supraclavicular and 3 cm in the bilateral axillary and inguinal regions. The laboratory findings of the patient are summarized in Table 1. Evaluation of the initial laboratory parameters showed mild anemia and leukopenia, a high erythrocyte sedimentation rate (ESR), a high C-reactive protein (CRP) level, increased lactate dehydrogenase (LDH), a albumin globulin rate less than 1, a high CA-125 level, and low vitamin B12. The erythrocytes were normochromic normocytic; mild monocytosis (16%) but no atypical cells were seen in the peripheral blood smear. In the analysis of the ascites fluid, the serum ascitic albumin gradient (SAAG) was <1.1 g/dl, the cell count was 1600 leukocytes/mm3 (70-80% mononuclear), the value of adenozine deaminase (ADA) was 60.4 U/l, and the LDH was high (281 U/L). No malignancy finding was found during the cytological evaluation of the ascites fluid. No bacteriological growth in the ascites fluid culture was observed. She was euthyroid and HIV seronegative. Her hepatitis B and C tests were negative and her coagulation tests were normal. Fecal occult blood revealed a negative result 3 times. No sign of heart failure was detected in both her echocardiography and her physical examination. Chest X-ray revealed bilateral reticulonodullary infiltration (Fig. 1A).
On the abdominal USG, there was a LAP of 2 cm in the hepatic hilum and ascites, but no hepatosplenomegaly. The USG scans of the axillary, inguinal, and cervical regions also revealed hypoechoic, lobulated, and heterogenous multiple LAPs. Ground-glass density areas in both lungs, especially in the left one, were seen on thoracic CT (Fig. 1B). On abdominal computed tomography (CT) multiple LAPs were observed in paraaortic region. Ascites, ventral abdominal mesenteric heterogenity and thickness were seen on CT image as well (Fig. 2A). For the exclusion of an occult malignancy, an upper gastrointestinal system endoscopy was performed, and reflux esophagitis was seen. She was consulted to our Gynecology Department to rule out gynecologic malignancies since the serum level of CA-125 was high. A gynecologic examination revealed no pathological finding so a screening PAP smear test and an endometrial curettage were performed. No pathological finding was found in mammographic scan. A supraclavicular lymphadenectomy was performed for a diagnosis. The pathology of the lenfoid tissue and endometrial biopsy showed caseification necrosis in some granulomas. Her PAP smear showed a negative result for malignancy. The intradermally performed purified protein derivative (PPD) test was 15 mm. The direct microscopic examining of induced sputum acid-resistant bacilli (ARB) was negative and sputum cultures for MTB were performed. After all of the diagnostic tests, genital TB became suspicious. A tetrad treatment with isoniasid 300 mg/day, rifampycin 600 mg/day, pyrazinamide 1500 mg/day, etambuthol 1500 mg/day was started. Sputum culture before the treatment was positive for MTB. Four months after the initiation of the treatment, her hemoglobin and CA-125 levels turned to normal. The ascites had disappeared, the diameters of the LAPs had significantly decreased, and the symptoms of the patient had all regressed.