We report the case of a 44-year-old multiparous woman, without previous medical history, having a positive family history for breast cancer in her paternal aunt. She presented elsewhere for a one-month history of cough and abdominal distention, followed by episodes of fever at 39 C. Abdominal ultrasound was done, showing large ascites and a right ovarian mass.
An abdominopelvic MRI was done showing a hyperintense, heterogeneous mass of the right ovary, measuring 20 x 17 mm, with restriction of diffusion, in favor of a malignant process.
Tumor markers showed an elevated CA 125 level of 543 and normal CA 19-9 level of 13.2. Serum C-reactive protein (CRP) was 53.
A diagnostic abdominal tap was done with cytology examination showing no malignant cells in the peritoneal fluid.
A PET/CT scan was also done revealing peritoneal thickening and diffuse peritoneal fixation with hypermetabolism at the right ovary (SUV = 6.7) of 2 cm, as well as bilateral pleural fluid that was not hypermetabolic.
The patient was admitted at our department for further investigations. New work-up with total body CT scan was done showing moderate enhanced ascites associated with mesenteric fat streaking with millimetric nodules suggestive of peritoneal carcinomatosis (Figure 1).
Abdominal tap was repeated revealing only inflammatory reaction and serous fluid without evidence of malignant cells and with negative culture. An ultrasound-guided Tru-cut biopsy of the peritoneum was performed and revealed only inflammatory changes without malignant cells. Right pleural fluid was aspirated and sent for cytology and culture. Analysis showed no evidence of bacteria, infection, or malignant cells.
Ultimately, a laparoscopic exploration was done with multiple biopsies taken from peritoneal nodules. Histological result showed a necrotizing, epithelioid, and gigantocellular granulomatous reaction, with Ziehl staining showing exceptional acido-alcohol resistant bacilli compatible with Koch bacilli (Figure 2). Subsequently, pulmonary sampling was done and samples were analyzed for Mycobacterium tuberculosis by polymerase chain reaction (PCR), with a negative result showing no sign of pulmonary infection.
The patient was started on quadritherapy (rifampicin, isoniazid, ethambutol, and pyrazinamide) for 2 months with significant improvement in her clinical picture and weight gain of 4 kg and will continue for an additional 6 months of biotherapy with rifampicin and isoniazid. Follow-up imaging with abdominal MRI was done showing no ascites or masses in the abdomen.