Introduction: Peritoneal tuberculosis is an uncommon site of extrapulmonary infection caused by Mycobacterium tuberculosis (TB). Patients with cirrhosis, HIV infection, diabetes mellitus, underlying malignancy, following treatment with anti-tumor necrosis factor (TNF) agents, and in patients undergoing continuous ambulatory peritoneal dialysis are high risk to be infected.
It can also occur via hematogenous spread from active pulmonary or miliary TB. Rarely, the organisms enter the peritoneal cavity transmurally from an infected small intestine or contiguously from tuberculous genital organ.
In this case report, we present a case of pelvic tuberculosis without lung manifestation.
Case Reports: A 59 year old/ Para 3, menopause 10 years ago with underlying diabetes mellitus, hypertension and dyslipidaemia, presented with a 2 weeks history of abdominal distension and discomfort. Otherwise she didn’t feel any abdominal mass, constitutional symptoms, post menopausal bleeding/ abnormal PV discharge, urinary or bowel symptoms. She has no family history of malignancy.
During admission for CT scan, she experienced high grade fever which occurred mainly late in the evening/night for 14 days. All septic workouts were normal, Infectious Disease specialist treated her as tumour induced fever with 7 days of IV Ceftriaxone and Metronidazole. The fever settled temporarily prior to operation.
Examination: General examination revealed a thin lady, not pale, with no palpable lymph nodes. Examination of cardiovascular and respiratory systems were unremarkable. The abdomen was grossly distended, filled with ascites, and no palpable mass/hepatosplenomegaly. Bimanual examination revealed an atrophic uterus, with no adnexal/POD mass.
Investigation: Bedside ultrasound revealed gross ascites, an atrophic uterus, and presence of left ovarian solid mass measuring 3×3 cm, with irregular margin. The right ovary was atrophic, both liver and kidneys were normal. CT scan thorax/abdomen/pelvis showed a left ovarian tumour, measuring 3.3×2.9×1.9 cm with mixed solid cystic component, associated with gross ascites, and minimal right pleural effusion. The uterus and right ovary were normal. Serum Ca125 was 393 IU, other tumour markers were normal. Malignant ovarian tumour was suspected. Paracentesis of the peritoneal fluid showed no malignant cells.
Management: She underwent exploratory laparotomy + Total Abdominal Hysterectomy and bilateral salphingo-oopherectomy + omentectomy. Intraoperatively the ascites fluid measured 1,000 ml, and there was generalised small tumour deposits (measuring 0.5-1 cm) all over the peritoneal cavity, uterus and tubes; bowels, appendix, up to the surface under the diaphragm. With both normal appeared ovaries, diagnosis of primary peritoneal malignancy at least stage 3C was made.
Post-operative Follow-up: Differential diagnosis of peritoneal TB was made in view of the tumour deposits appearance, negative cytology results and moderately raised Ca125. Mantoux test was negative, and the AFB stain on the peritoneal fluid was negative too. The right pleural effusion resolved post-operatively. The peritoneal cytology was also sent for Mycobacterium C&S, and the result was still pending.
HPE result confirmed severe granulomatous inflammation due to Mycobacterium infection of the endocervix, endometrium, myometrium, both fallopian tubes and ovaries. Epithelioid granulomata involving medium sized arterial wall encroaching lumen of arteries in right fallopian tube. There was also presence of ulceration of surface mucosa of endocervix, endometrium, fallopian tube due to granulomata.
Final diagnosis of extra pulmonary TB was made, and anti-TB drugs regimen was started immediately. She recovered well then. Currently she is still under gynaecology outpatient and TB clinic follow up.
Discussion & Clinical Presentation: Pelvic tuberculosis without lung manifestation is a very rare condition. Patient may present with ascites (93 per cent), abdominal pain (73 per cent), and fever (58 per cent). Abdominal pain and ascites were also the most common presenting features in several reports. It can mimic ovarian malignancy or peritoneal malignancy symptoms.
Tuberculosis can affect the upper female reproductive tract by extension from direct intraabdominal spread, hematogenous seeding, or ascending from lower genital tract infection. The fallopian tube and endometrium are the most common involved organs. Endometrial tuberculosis always associated with salpingitis but tuberculous salpingitis may exist without associated endometritis.
Investigation: The gold-standard for diagnosis is culture growth of Mycobacterium on ascitic fluid or a peritoneal biopsy. The diagnosis usually requires a peritoneal biopsy performed under direct visualization. Blind peritoneal biopsies have a low success rate and have been associated with complications including death Laparoscopic guided biopsy appears to be relatively safe. Study reported complication rate was 2.7 per cent in four series comprising of 110 patients. Peritoneal biopsy via mini-laparotomy may be preferred by some surgeons and should be considered if laparoscopy is non-diagnostic. Visual diagnosis during laparoscopy or mini-laparotomy able to diagnose up to 95 per cent of cases. Typically, the visceral and parietal peritoneum is studded with multiple whitish nodules or tubercles. Other findings include enlarged lymph nodes, “Violin-string” fibrinous strands, and omental thickening.
Tissue biopsies reveal caseating granulomas in up to 100 per cent of patients and are positive for acid fast bacilli in 74 per cent of patients. In our case, the growth culture was negative but histo-pathology of the tissue biopsy showed positive acid fast bacilli and confirmed peritoneal tuberculosis.
Treatment: The treatment regimens for tuberculous peritonitis is same as the treatment for pulmonary tuberculosis.
Conclusion: In conclusion, peritoneal tuberculosis is a rare condition which can mimick ovarian malignancy or peritoneal malignancy, especially in patient without pulmonary manifestation and negative TB investigations. This may cause dilemma in management of young patients. More case series and study is needed to improve our assessment in future especially prior to surgery.
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