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Arch Gynecol Obstet (2009) 280:333335 DOI 10.

1007/s00404-009-0946-y

LE TTER TO THE EDIT OR

Peritoneal tuberculosis with elevated serum Ca-125 level mimicking advanced stage ovarian cancer: a case report
Orkun Tan Edward Luchansky Stephen Rosenman Tarah Pua Masoud Azodi

Received: 3 January 2009 / Accepted: 9 January 2009 / Published online: 31 January 2009 Springer-Verlag 2009

Abstract Background Tuberculosis is still a common problem in immigrant population with peritoneal tuberculosis as the most common presentation of extrapulmonary disease. Case A 36-year-old woman presented with abdominal distention, night sweats and weight loss. Physical examination and radiologic studies revealed ascites, omental caking and bilateral enlarged ovaries with an elevated serum Ca-125 of 353 U/mL. Acid-fast stain and culture were negative for Mycobacterium tuberculosis. Diagnostic laparoscopy and biopsy revealed multiple granulomas with epithelioid cells and caseiWcation necrosis conWrming tuberculosis. Treatment with anti-tuberculin drugs resulted in resolution of symptoms with a reduction in Ca-125 to normal. Conclusion Laparoscopic biopsy with frozen section evaluation would spare patients with peritoneal tuberculo-

sis from unnecessary extensive surgery. Serum Ca-125 level may be useful in monitoring treatment response. Keywords Ca-125 Peritoneal tuberculosis Ovarian cancer

O. Tan (&) T. Pua Department of Obstetrics and Gynecology, New York University School of Medicine, Bellevue Hospital, 462 E. 1st Av. 9S, New York, NY 10016, USA e-mail: tano01@med.nyu.edu E. Luchansky S. Rosenman Department of Obstetrics and Gynecology, Bridgeport Hospital, Bridgeport, CT 06610, USA M. Azodi Department of Obstetrics and Gynecology, Yale University School of Medicine, New Haven, CT 06520, USA

Peritoneal tuberculosis may present with nonspeciWc signs and symptoms such as ascites, abdominal pain and distension, similar to ovarian cancer [1]. We report a case of peritoneal tuberculosis mimicking advanced stage ovarian cancer with an elevated Ca-125 level. A 36-year-old gravida three para two female who immigrated from India 10 years ago was seen for 6-month history of malaise, increased abdominal girth, night sweats and weight loss of eight pounds. Abdominal and pelvic computerized tomography (CT) revealed a heterogeneous soft tissue mass measuring 5.7 3.2 cm in size within the region of the porta hepatis, omental caking, moderate amount of ascites, multiple pathologic retroperitoneal lymphadenopathies, and bilateral multicystic ovarian lesions. Serum Ca-125 level was elevated to 353 U/mL (normal range 035 U/mL). Intraoperative Wndings via laparoscopy revealed multiple nodules measuring approximately 14 cm located on the diaphragmatic surfaces, anterior abdominal wall and the parietal peritoneum. The ovaries were multicystic appearing with mild irregularity on the right ovarian surface. Biopsy samples from the parietal peritoneum, diaphragmatic surfaces and right ovary were sent for pathologic examination with frozen section. Frozen evaluation of the right ovary showed no malignancy. Histopathologic examination of the specimens revealed multiple granulomas with epithelioid cells and caseiWcation necrosis as well as multinucleated giant cells (MNGCs) in all samples (Fig. 1). No further surgery was

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Arch Gynecol Obstet (2009) 280:333335

Fig. 1 Histologic examination revealed multiple granulomas with epithelioid cells and caseating necrosis (between two arrows). A multinucleated giant cell that is characteristic of tuberculosis is seen (black square)

performed and anti-tuberculin regimen of rifampicin 900 mg/day, pyrazinamide 2 g/day, streptomycin 1 g/day and isoniazid 300 mg/day was initiated. Follow-up abdominal CT scan showed signiWcant improvement in all lesions 4 months after the initiation of the therapy (Fig. 2b, d). The previously noted moderate amount of ascites decreased dramatically (Fig. 2a, b), along with the heterogeneous soft tissue mass in the porta hepatis region (Fig. 2c, d). Furthermore, the left ovarian mass was signiWcantly reduced in size (Fig. 3a, b). One year after initiation of therapy, the patients Ca-125 level was back to a normal level of 19 U/ml. Peritoneal tuberculosis should be considered in the diVerential diagnosis of a patient with positive PPD with uni or bilateral adnexal masses, omental caking, ascites and elevated serum CA 125 [2, 3]. Acid-fast staining and special cultures of the ascitic Xuid for M. Tbc. are frequently negative, and conWrmation of the diagnosis requires laparoscopic biopsy with frozen section evaluation which could spare a signiWcant number of patients from unnecessary extensive surgery [4]. Serial measurements of CA 125 may be useful in monitoring response to anti-tuberculosis medications.
Fig. 2 Pathologic retroperitoneal lymphadenopathies (under the red curve) with abdominal ascites (white arrow) prior to the initiation of the anti-tuberculosis treatment as seen in a. The number and size of retroperitoneal lymphadenopathies and the amount of ascites signiWcantly improved after the initiation of the anti-tuberculosis treatment (b). An inWltrative heterogeneous mass within the porta hepatis region (red circle) is seen in c. The size of this lesion signiWcantly reduced after the initiation of the anti-tuberculosis treatment (d)

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Arch Gynecol Obstet (2009) 280:333335 ConXict of interest statement None.

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References
1. Straughn JM, Robertson MW, Partridge EE (2000) A patient presenting with a pelvic mass, elevated CA-125, and fever. Gynecol Oncol 77:471472. doi:10.1006/gyno.2000.5756 2. Wu JF, Li HJ, Lee PI, Ni YH, Yu SC, Chang MH (2003) Tuberculous peritonitis mimicking peritonitis carcinomatosis: a case report. Eur J Pediatr 162:853855. doi:10.1007/s00431-003-1319-3 3. Bilgin T, Karabay A, Dolar E, Develioglu OH (2001) Peritoneal tuberculosis with pelvic abdominal mass, ascites and elevated CA 125 mimicking advanced ovarian carcinoma: a series of 10 cases. Int J Gynecol Cancer 11:290294. doi:10.1046/j.1525-1438.2001. 011004290.x 4. Koc S, Beydilli G, Tulunay G, Ocalan R, Boran N, Ozgul N et al (2006) Peritoneal tuberculosis mimicking advanced ovarian cancer: a retrospective review of 22 cases. Gynecol Oncol 103:565569. doi:10.1016/j.ygyno.2006.04.010

Fig. 3 Bilateral adnexal lesions (red circles) as seen in a. The left adnexal lesion a signiWcantly improved, however, a small unilocular cystic mass (b; red circle) persisted after the initiation of the anti-tuberculosis therapy. The right adnexal mass a was removed at the time of laparoscopy for tissue diagnosis. The duration between two CT scans is 4 months. R right

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