A 57 year old female presented with complaints of abdominal pain for 3 weeks. The pain was dull, aching, and intermittent. She reported a history of constipation, chronic hypertension diagnosed 4 years ago and no history of TB. A history of night sweat, fatigue, weight-loss, and chronic cough or any contact with a pulmonary TB patient was denied. The patient had a previous history of hemorrhoid surgery only.
On clinical examination was the blood pressure 110/70 mmHg, heart rate 76/min and the body temperature 36.8C. The abdomen was soft, no distended, non-tender and no mass was palpable; but there was a presence of small amounts of ascites. There was no palpable cervical lymph node. Other systemic examinations including cardiovascular system and lungs showed normal results.
Biochemically, her hemoglobin was 13.3 g/dL, total white cells were 11,940 103/microL and the C reactive protein was 4.05 mg/dL, otherwise all values were normal. Serum CA-125 levels were elevated (228.6 IU/mL) and serum CA-19-9 levels were normal (<2.0 IU/mL). The chest X-ray was normal. An abdomen CT revealed the presence of an enhancing thickening of the peritoneum, hepatic capsule, omentum and ascites and calcific lymph nodes of the lower abdominal and pelvic cavity (Fig. 1). CT findings suggested a tuberculous peritonitis, but could not rule out a tuberous peritonitis or Fitz-Hugh-Curtis syndrome. The tuberculin skin test result (Mantoux skin test) was positive and interferon-gamma release assays (QuantiFERON TB Gold, Cellestis, Victoria, Australia) were positive as well. So, a tuberculous peritonitis was suggested for this patient.
Under this impression, we performed an exploratory laparoscopy for an accurate diagnosis before the TB treatment. There was no mass was observed, neither in the uterus, both ovaries, both salpinges, omentum nor in the peritoneal surface which could be considered as an intraperitoneal malignancy (Fig. 2A, B). Intraperitoneal severe adhesions and small amounts of ascites raised the suspicion of an intra-abdominal tuboovarian abscess. Also suspicious lesion of TB peritonitis was seen (Fig. 2C). Peritoneal washing and peritoneal adhesiolysis was done and a peritoneal ascites probe was sent for bacteriologic and TB evaluation. Also tissue biopsies of the adhesion sites were sent. The acid fast bacilli stain smear test in the peritoneal fluid was negative and the results of Gram stain & bacterial culture were negative as well. The adenosine deaminase in the peritoneal fluid was with 14.0 U/L (6.8-18.2 U/L). No histopathologic evidence of tuberculous granuloma was observed on microscopic examination in the peritoneal fluid. The culture and the examination for a polymerase chain reaction of the sputum did not reveal TB. There was no evidence of TB detected in the lung or pelvic cavity and the patient was subsequently not diagnosed with TB peritonitis but with latent TB therefore.
The pelvic cavity biopsy confirmed the diagnosis of a serous papillary adenocarcinoma. A positron emission tomography (PET)-CT at another hospital revealed a malignancy of both ovary with lymph node metastasis and peritoneal carcinomatosis. After the diagnosis as ovarian cancer, paclitaxel and carboplatin were administered every 3 weeks for treatment.