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 Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 4  |  Issue : 1  |  Page : 36-38

Isolated ovarian tuberculosis: Case report and literature review


1 Department of Pathology, SHKM, GMC, Mewat, Haryana, India
2 Department of Surgery, SHKM, GMC, Mewat, Haryana, India

Date of Web Publication13-Jan-2015

Correspondence Address:
Manmeet Kaur Gill
#22265/A, Shant Nagar, Bathinda, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-344X.149258

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  Abstract 

Although genitourinary tuberculosis (TB) is common, reports of isolated ovarian TB are rare. However, its presentation can mimic that of an ovarian tumor, leading to diagnostic difficulties. A 25-year-old woman presented with chronic pelvic pain, weight loss, a right ovarian mass on ultrasound, and a significantly elevated cancer antigen 125 (CA-125) level. Laparotomy was performed with resection of the right ovary. Postoperative histological examination, however, revealed evidence of TB, with no signs of malignancy. Anti-TB treatment was commenced, with full resolution of her symptoms and a decrease in CA-125 level. Isolated ovarian TB is most common in young women living in endemic zones. CA-125 can be raised in many conditions, and imaging is rarely conclusive. Intraoperative frozen section of tissue specimens can be helpful if available. Early diagnosis of ovarian TB is vital as untreated disease can lead to infertility.

Keywords: Infertility, ovary, tuberculosis


How to cite this article:
Gill MK, Bains SP, Rana S. Isolated ovarian tuberculosis: Case report and literature review. Int J Health Allied Sci 2015;4:36-8

How to cite this URL:
Gill MK, Bains SP, Rana S. Isolated ovarian tuberculosis: Case report and literature review. Int J Health Allied Sci [serial online] 2015 [cited 2022 Jan 23];4:36-8. Available from: https://www.ijhas.in/text.asp?2015/4/1/36/149258


  Introduction Top


Tuberculosis (TB) remains a significant public health problem worldwide. There were an estimated 9.2 million new cases and 1.7 million deaths from TB in 2008. [1] Although genitourinary disease is common, isolated ovarian TB is rare. [2] Herein we report a case of ovarian TB in a young female. The clinical features and diagnosis of ovarian TB are discussed, with a review of the literature.


  Case Reports Top


A nulliparous woman, aged 25 years, presented to the hospital with a 2 months-history of pelvic pain. This was associated with a low-grade fever, weakness, and anorexia. She also reported a weight loss of 4 kg in 6 months. She is married since 3 years and suffered from infertility. She had received the bacille Calmette-Guerin (BCG) vaccination at birth, and there was no history of contact with TB.

The patient had attained menarche at 12 years of age and had regular cycles. However, her last menstrual period was over 4 months ago. Vaginal examination revealed a mass in right fornix, tender on palpation. Blood tests showed a moderate anemia with a hemoglobin of 10 g/dL, and an erythrocyte sedimentation rate of 90 mm. Tumor markers were measured, and the level of cancer antigen 125 (CA-125) was 450 U/mL. HIV serology was negative.

Plain radiography of chest and abdomen was normal. Pelvic ultrasound demonstrated a heterogeneous right adnexal mass of 60 × 55 mm and a mild ascites in the sac of Douglas. Laparotomy revealed a discrete cystic mass in the right ovary which was fully excised [Figure 1]. The rest of the peritoneal cavity was completely unremarkable.
Figure 1: Cut open gross of cystic ovarian mass

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Postoperative histopathological examination showed giant cells and epithelioid cell granuloma with central caseous necrosis [Figure 2]. There was no sign of malignancy, and the diagnosis was ovarian TB. No other focus of TB was found, including pulmonary and genitourinary disease. Endometrial biopsy showed no evidence of TB with endometrium in the proliferative phase. Anti-TB treatment was commenced. Recovery was marked by complete resolution of the pelvic pain, a weight gain of 2 kg in 2 months, normalization of her menstrual cycles, and a decrease in the CA-125 level.
Figure 2: Histopathology showing giant cells and epitheloid cell granuloma with central caseous necrosis

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  Discussion Top


Genitourinary TB is the second most frequent location for extra-pulmonary TB, after the lymphatic system. [3] This site can represent up to 19% of gynecological admissions in some developing countries. [4] The endometrium and  Fallopian tube More Detailss are almost always affected by the disease. The ovaries were involved in 62.5% of cases in one study. [5] However, isolated ovarian TB with no other organ involvement as in this case, is rarely reported in the literature.

It classically affects young women aged 20-30 years who are living in endemic zones. However, with increased immigration, travel, and the re-emergence of TB worldwide, reports from Western countries are also found. [6],[7]

Pulmonary TB may be detected prior to the ovarian disease. However this is not obligatory, as demonstrated by our case. Presenting symptoms include infertility, pelvic pain, abdmino-pelvic masses, ascites, weight loss and menstrual problems such as amenorrhea and dysmenorrhea. [2] However, the patient can also be asymptomatic, which is estimated to account for at least 11% of cases in the population. [8]

Preoperative tests which may aid the diagnosis include a positive Mantoux (tuberculin) test, and staining for acid-fast bacilli in either ascitic or pleural fluid. However, these may be negative despite extensive disease. [9]

Cancer antigen 125 is an antigenic determinant which is expressed in most nonmucinous epithelial ovarian carcinomas and is raised in more than 80% of cases. [2],[7] It is very useful in postmenopausal women where the positive predictive value for malignancy is nearly 95%. [6] However, in premenopausal women, it can be elevated by benign conditions such as endometriosis, fibroids, and pelvic inflammatory disease, and indeed TB. [7] In the case of ovarian TB, its level rarely rises above 500 U/mL (450 U/mL in this case). [2] Simsek et al. have shown that decreasing levels of CA-125 correlate with the resolution of the disease on anti-tuberculous treatment. They suggest that serial measurements should be used to determine treatment efficacy. [10]

Imaging has low specificity, with both an ovarian malignancy and a tuberculous abscess having similar appearances on ultrasound, computerized tomography, and magnetic resonance imaging. Both can be heterogeneous masses, which can infiltrate omentum and neighboring organs. Ascites and lympadenopathy are both frequently present, further confusing the diagnosis. [2] Ultrasound-guided transvaginal or transabdomenal biopsies may be used for preoperative diagnosis.

Intraoperative frozen section of tissue specimens can be very helpful in oncological surgery. Although histological demonstration of TB can be difficult, the lack of malignant cells may indicate an alternative diagnosis. This would be recommended if the resources are available. [7]

Treatment for genital TB is medical. Although most cases resolve with antitubercular treatment, the long-term prognosis for patients' fertility is poor. One study estimated that pelvic TB was responsible for more than 39% of cases of tubulo-ovarian. [2] Early diagnosis and the prevention of TB, including BCG immunization campaigns, are important in order to avoid this devastating outcome.


  Conclusion Top


Isolated ovarian TB is rare. Its presentation can mimic that of an ovarian malignancy, including an ovarian mass, ascites and a rise in CA-125 level. It should be kept in mind as a differential diagnosis, both in developing and developed countries.

 
  References Top

1.
World Health Organization. Global Tuberculosis Control Report. Geneva: World Health Organization; 2008.  Back to cited text no. 1
    
2.
Nebhani M, Boumzgou K, Brams S, Laghzaoui M, El Attar H, Bouhya S, et al. Pelvic tuberculosis mimicking bilateral ovarian tumor. A case report. J Gynecol Obstet Biol Reprod (Paris) 2004;33:145-7.  Back to cited text no. 2
    
3.
Watfa J, Michel F. Uro-genital tuberculosis. Prog Urol 2005;15:602-3.  Back to cited text no. 3
    
4.
Sfar E, Ouarda C, Kharouf M. Female genital tuberculosis in Tunisia. Apropos of 118 cases at the Rabta Neonatology and Maternity Center in Tunis (January 1984-December 1988). Rev Fr Gynecol Obstet 1990;85:359-63.  Back to cited text no. 4
    
5.
Agarwal J, Gupta JK. Female genital tuberculosis - A retrospective clinico-pathologic study of 501 cases. Indian J Pathol Microbiol 1993;36:389-97.  Back to cited text no. 5
    
6.
Pesut D, Stojsic J. Female genital tuberculosis - A disease seen again in Europe. Vojnosanit Pregl 2007;64:855-8.  Back to cited text no. 6
    
7.
Straughn JM, Robertson MW, Partridge EE. A patient presenting with a pelvic mass, elevated CA-125, and fever. Gynecol Oncol 2000;77:471-2.  Back to cited text no. 7
    
8.
Varma TR. Genital tuberculosis and subsequent fertility. Int J Gynaecol Obstet 1991;35:1-11.  Back to cited text no. 8
    
9.
Jana N, Mukhopadhyay S, Dhali GK. Pelvic tuberculosis with elevated serum CA125: A diagnostic dilemma. J Obstet Gynaecol 2007;27:217-8.  Back to cited text no. 9
    
10.
Simsek H, Savas MC, Kadayifci A, Tatar G. Elevated serum CA 125 concentration in patients with tuberculous peritonitis: A case-control study. Am J Gastroenterol 1997;92:1174-6.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2]


This article has been cited by
1 “Silent” Post-Menopausal Genital Tuberculosis with lethal outcome
E. Gazos,O. Tsonis,F. Gkrozou,M. Paschopoulos
Indian Journal of Tuberculosis. 2019;
[Pubmed] | [DOI]



 

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