A 67-year-old para 2 African-American female presented to her primary provider complaining of abdominal pain and distention for 2 weeks, a 10 lb weight loss, and shortness of breath. Past medical history was significant for well-controlled hypertension. Past surgical history included an abdominal myomectomy and two cesarean deliveries. Outpatient abdominal sonogram showed a 1.3 x 1.8 x 2 cm pancreatic head mass with multiple hypoechoic lesions throughout the pancreas, the largest measuring 3.2 cm. Tumor markers were sent and resulted in CEA < 0.5 ng/mL, CA 19-9: 19 U/mL, CA-125: 434 U/mL. Further imaging was ordered including CT scan with contrast which revealed an 8 x 8 x 7 cm pelvic mass, ascites, peritoneal nodularity, and lymphadenopathy. The patient was referred to the emergency department (ED) for drainage of the ascites, additional imaging, and biopsy. In the ED, a CT of the chest showed left cervical, superior mediastinal, left paratracheal, epicardial, and perihepatic lymphadenopathy with a moderate right-sided pleural effusion. A MRI revealed a 12 x 7.5 x 7.8 cm uterus with 2.4 x 2.3 cm right ovarian mass, peritoneal nodules, dense omental carcinomatosis extending into the anterior pelvis, and para-aortic paracaval adenopathy extending from renal hilum to the aortic bifurcation with no visible pelvic adenopathy. This patient was referred to the institution's division of gynecologic oncology where an omental mass biopsy was ultimately performed demonstrating noncaseating granulomas with no tumor identified. The ascitic fluid was negative for malignancy.
The patient was discharged and referred to our division of gynecologic oncology for a second opinion with a suspicion of advanced-stage ovarian cancer. After obtaining a detailed history, decision was made to perform a diagnostic laparoscopy and obtain tissue samples prior to planned surgical treatment. The patient underwent diagnostic laparoscopy and tissue sampling. Diffuse disease representing presumed carcinomatosis was encountered (Figure 1). Subsequent biopsies and frozen section revealed noncaseating granulomas with no evidence of malignancy. Preliminary acid fast bacilli (AFB) stains were negative (Figure 2). Four (4) weeks later, preliminary results from AFB tissue culture were positive for Mycobacterium tuberculosis with final confirmation six (6) months after. The patient was subsequently diagnosed with disseminated pelvic tuberculosis (TB) and referred to the division of infectious diseases for combination therapy.