tuberculosis ( tb ) is the second leading cause of death from infectious diseases worldwide . in the year 2012 , an estimated 8.6 million people developed tb , and 1.3 million died from the disease .
pelvic and peritoneal tb may resemble advanced ovarian cancer due to the presence of ascites , complex adnexal mass , peritoneal deposits , and raised ca-125 level .
symptoms such as weight loss , reduced appetite , and dull abdominal pain are also common to these two conditions .
quite often , the diagnosis of tb is made after a laparotomy for suspected ovarian cancer .
hence , it is important to review these two entities in detail to arrive at a diagnosis prior to performing a major surgical procedure .
we have earlier reported four women with pelvic tb who were diagnosed after laparotomy or laparoscopy for suspected ovarian cancer . from july 2012 to june 2015 , we treated ten women in peri- and post - menopausal age group where this diagnostic dilemma arose of whom seven underwent laparotomy for suspected ovarian cancer .
we report four perimenopausal and six postmenopausal women who presented with features mimicking ovarian malignancy but were finally diagnosed to have pelvic - peritoneal tb .
all were parous with no history of infertility , hiv negative , had a normal chest x - ray , and raised ca-125 level .
all presented with abdominal pain and distension of varying duration of 1 month to 3 years .
two women had a history of loss of appetite and weight also , and only one woman gave a history of low - grade fever for a month .
radiological imaging in these women showed complex adnexal masses ranging from 3 to 15 cm ; eight among them had ascites .
ascitic fluid analysis was done in four which showed a lymphocytic predominant pattern with adenosine deaminase ( ada ) levels ranging from 18 to 70 ( normal < 30 u / l ) , and absence of malignant cells .
ca-125 was elevated in all ( normal < 35 iu / ml ) and ranged between 144 and 1643 iu / ml .
iu / l was found in three women . polymerase chain reaction ( pcr ) amplification , despite its limitations , can be useful for the detection of mycobacterial dna in ascitic fluid , allowing a specific diagnosis to be made rapidly .
one woman was prescribed antituberculosis treatment ( att ) based on her clinical profile ( abdominal pain and distension , fever , and loss of weight and appetite from 1 month ) and ultrasound imaging ( 4 cm  2 cm complex adnexal mass and exudative ascites with ada = 70 ) .
the adnexal masses were not approachable for fine - needle aspiration ( fna ) . her symptoms improved and ascites resolved after 1 month of initiating att .
two women had histopathological diagnoses of pelvic peritoneal tb following fna of the adnexal mass .
u / l and fine - needle aspiration cytology ( fnac ) of the adnexal mass revealed granulomatous pathology consistent with tb .
the other woman was aged 77 years who presented with abdominal distension from 4 months .
abdominal and pelvic imaging reported moderate ascites with omental and peritoneal thickening with complex bilateral adnexal masses and collection within the endometrial cavity suggestive of pyometra .
she underwent pyometra drainage and fnac from the adnexal mass which was consistent with tb .
seven women underwent laparotomy due to suspected ovarian cancer . in five , intraoperative findings of tubercles on the pelvic organs and peritoneal surfaces suggested tb and frozen section of biopsies from tube , ovary , peritoneum , and omentum confirmed tb . in two , tb was not suspected intraoperatively , and diagnosis was made postoperatively based on histopathology reports . in a 42 year old woman , para 4 with abdominal distension , pain , significant loss of weight , and ca-125 of 1643
her imaging showed bilateral adnexal masses and ascites . at laparotomy , there were multiple deposits over uterus , pelvic organs , and peritoneal surfaces .
the right ovary was normal and left ovary had a cyst measuring 4 cm  4 cm .
hysterectomy , bilateral salpingo - oophorectomy , and infracolic omentectomy were performed . the other woman presented with uterine prolapse and a right adnexal mass which appeared benign on imaging .
the adnexal mass could not be removed vaginally due to adhesions , and laparotomy had to be performed to remove it .
the common features mimicking ovarian cancer are weight loss , reduced appetite , diffuse abdominal pain and distension , ascites ( exudative ) , complex ( solid - cystic ) adnexal masses , peritoneal and omental deposits , retroperitoneal lymphadenopathy , and raised serum ca-125 . although india is an endemic country , the diagnosis of pelvic and peritoneal tb is often missed until a laparotomy is performed for suspected ovarian cancer .
concerns about missing or delaying the diagnosis of ovarian cancer result in an exploratory laparotomy , salpingo - oophorectomy , and hysterectomy in some of these women .
oge et al . reported twenty women with pelvic and peritoneal tb who were initially thought to have ovarian cancer .
diagnostic laparotomy , laparoscopy , and ultrasound - guided tru - cut biopsy were performed in 11 , 2 , and 7 women , respectively , and histopathology showed tb .
the most common symptom was abdominal pain ( 70% ) and distension ( 65% ) .
ca-125 levels were elevated in 80% ( mean 289  186.2 iu / ml ) . a ct scan or ultrasound showed the presence of ascites in 85% and a pelvic mass in 60% . in the present series , nine women had abdominal distension with or without pain ; all had elevated ca-125 and pelvic masses on imaging were seen in ten of them .
sonographically guided core biopsy of adnexal masses helped to diagnose tb in a gyneoncology unit in turkey in 55 women suspected to have ovarian cancer .
a biopsy was done for women likely to have suboptimal cytoreduction ( 58.2% ) , a poor performance status ( 20.0% ) , and suspected nongynecologic tumors ( 21.8% ) .
histopathology revealed primary ovarian tumors in 65.5% and tb was the second most common disease ( 14.5% ) .
this technique may be useful when peritoneal tb is considered in the diagnostic workup of women with adnexal masses and exudative ascites which has raised ada level ( > 30 iu / l ) and is negative for malignant cells .
fnac was used as a diagnostic modality in two of our cases . the median serum ca-125 level in epithelial ovarian cancer
was reported to be significantly higher than among women with peritoneal tb ( p  0.01 ) . among 48 women with peritoneal tb and 370 with epithelial ovarian cancer , only one ( 2.1% ) with peritoneal tb had a serum ca-125 level > 2000 iu / ml . however , 109 women ( 29.5% ) with epithelial ovarian cancer had a serum ca-125 level > 2000 iu / ml . at the ca-125 ranges of 400 to 599 and 600 to 799 , the proportions of those with peritoneal tb were 24% and 21.9% , respectively . at a serum ca-125 level
> 1000 iu / ml , the proportion of women with peritoneal tb was much lower ( 2.1% ) . in seven of our cases , ca-125 was < 600 iu / ml ( 146571 ) .
in one woman , the ca-125 was 1643 iu / ml and peritoneal tb was not suspected even at laparotomy .
a laparoscopic evaluation with biopsies is another option when the diagnostic dilemma persists , and we do not want to miss diagnosing ovarian cancer . whenever peritoneal tb is suspected intraoperatively , frozen section histology should be utilized so that unnecessary surgery is prevented . a diagnostic tool which may differentiate between the two conditions in the future is the xpert mtb / rif assay .
it is a real - time pcr assay that can be used by operators with minimal technical expertise , enabling diagnosis of tb and assessment of rifampicin resistance and has been endorsed by the who recently .
xpert mtb / rif may be used as a replacement test for usual practice ( conventional microscopy , culture , and histopathology ) for testing of specific nonrespiratory specimens ( lymph nodes and other tissues ) from patients presumed to have extrapulmonary tb .
it is a diagnostic challenge to differentiate pelvic - peritoneal tb from ovarian cancer which has entirely different management and prognosis and peritoneal and pelvic tb is a differential diagnosis to be remembered while evaluating women with bilateral complex adnexal masses , ascites , and moderately raised ca-125 level .
ascitic fluid showing lymphocytic predominance , raised ada , and no malignant cells are pointers to obtain a histopathological diagnosis by ultrasound - guided needle biopsy or laparoscopic biopsy or frozen section at laparotomy .
 pelvic and peritoneal tuberculosis may resemble advanced ovarian cancer due to the presence of ascites , complex adnexal masses , peritoneal deposits and raised ca-125 level , especially in peri- and postmenopausal women . 
 other common features among women with these two conditions are abdominal pain and distension , weight loss and reduced appetite . 
 as the treatment of pelvic - peritoneal tuberculosis is completely different from that of ovarian cancer , it is important to reach a correct diagnosis . 
 sometimes women with pelvic - peritoneal tuberculosis may be subjected to a laparotomy for suspected ovarian cancer which is likely to increase their morbidity . in the present article , 
 we report ten women in the peri- and post - menopausal age group where this diagnostic dilemma arose of whom seven were diagnosed only after a laparotomy had been performed for suspected ovarian cancer due to adnexal masses with ascites and raised ca-125 level . 
 ascitic fluid showing lymphocytic predominance , raised ada level and absence of malignant cells are pointers to consider the possibility of pelvic- peritoneal tuberculosis , especially in endemic countries like india . 
 in such situations , an effort should be made to obtain a cytological or histopathological diagnosis of either condition by ultrasound guided needle biopsy or laparoscopically obtained biopsy rather that proceeding with laparotomy for suspected ovarian cancer . 
INTRODUCTION
CASE REPORT
DISCUSSION
CONCLUSION
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