Brief history of the Present Illness:
A 58-year-old female presented with the chief complaint of generalized weakness and inability to walk. She was noted to be frail appearing and cachectic, with a significantly distended abdomen. She endorsed 1 year of progressive abdominal distension but had no other abdominal or gastrointestinal symptoms. On review of systems she also reported a 100-pound weight loss over the past year. She denied any subjective fevers/chills or night sweats.
Past Medical History including allergies (if relevant):
Diabetes mellitus, type 2
Key Medications (if relevant):
Epidemiological history (if relevant, such as habits, social and family history, animal exposures or travel):
She was originally from the Philippines and had immigrated to the United States twelve years earlier. She lived in Los Angeles with her sister, and was not currently employed. She reported previously working as a medical biller in the Philippines. She had no other significant risk factors in her social history. She reported a negative tuberculin skin test upon immigration to the United States twelve years earlier.
The patient was noted to be cachectic and frail appearing. She was febrile to 101.7oF (38.7oC). Her blood pressure was 158/73 mm Hg, pulse 72 beats per minute, respirations 16 breaths per minute, and oxygen saturation was 99% on room air. Her abdominal exam revealed a markedly distended abdomen, with a firm, large palpable mass (Figure 1) that was non-tender to palpation. The examination was otherwise normal.
Initial laboratory findings were significant for normal white blood cell count of 7.48 x 103/uL (reference range 4.16 – 9.95 x 103/uL), decreased hemoglobin to 10.7 g/dL (reference range 11.6 – 15.2 g/dL), and elevated CA-125 to 188 U/mL (reference range 0 – 35 U/mL). HIV testing was negative. Computed tomography of the abdomen and pelvis with contrast was performed and showed a large, 23-centimeter diameter heterogeneous mass that appeared to be arising from the pelvis, most likely of ovarian or uterine origin. Peritoneal thickening and enhancement, along with omental soft tissue nodularity, was noted and was felt to be consistent with peritoneal and omental carcinomatosis. Suggested differential diagnoses for the mass included ovarian malignancy, uterine leiomyosarcoma, or (less likely) benign large fibroid (Figure 2). Computed tomography of the chest with contrast displayed numerous enlarged intrathoracic lymph nodes (including mediastinal, left internal mammary and bilateral cardiophrenic angle lymph nodes) likely consistent with nodal metastasis.
Clinical Course Prior to Diagnosis (if relevant): Note Figures if appropriate.
On admission, she was empirically started on piperacillin/tazobactam given her fever and concern for possible bacterial superinfection within a likely malignant tumor. She remained persistently febrile and the infectious diseases service was consulted.
- Advanced ovarian malignancy
- Uterine leiomyosarcoma
- Abdominopelvic tuberculosis
- Benign uterine fibroid
- Disseminated Mycobacterium avium complex (MAC)
Diagnostic Procedure(s) and Result(s):
She underwent ultrasound-guided biopsy of her right upper quadrant omentum, which showed fibrous tissue with numerous non-necrotizing and well-formed granulomas as well as multinucleated giant cells. Acid-fast and fungal stains were negative. Shortly after this, a Quantiferon-TB Gold test returned positive. A second biopsy of the primary mass was performed, which did not reveal any viable tissue, and only showed necrotic material with rare epithelioid macrophages and inflammatory cells.
The diagnosis of Mycobacterium tuberculosis was considered, however after further reviewing her imaging with radiology, there was still high suspicion for malignancy given the size of the primary mass. Finally, a third biopsy was performed of the abdominal greater omentum, which again demonstrated granulomatous inflammation with no evidence of malignant cells. Acid-fast staining in the microbiology lab was negative, as was Mycobacterium tuberculosis polymerase chain reaction (PCR) testing. However, on pathology review, acid-fast staining of this specimen did reveal the presence of few scattered acid-fast bacilli (Figure 3). This specimen was later sent to the Centers for Disease Control and Prevention (CDC) laboratory, and polymerase chain reaction (PCR) testing was positive for Mycobacterium tuberculosis.
On hospital day 10, empiric treatment for Mycobacterium tuberculosis with rifampin, isoniazid, pyrazinamide and ethambutol was initiated. She remained hospitalized for approximately two months, and had intermittent interruptions and changes in her therapy due to elevated transaminases.
Of note, during her initial hospital course she had a happy affect, was very conversant, and frequently had family at the bedside. Upon discussing the suspicion for tuberculosis infection and initiation of anti-tuberculosis therapy, the patient became withdrawn, unmotivated to eat or get out of bed, and no longer had frequent visitors. She later revealed that she had been a physician in the Philippines years earlier, and had cared for several patients with tuberculosis. When she was asked if she had considered tuberculosis as an etiology for her significant weight loss and abdominal distension, she did not reply.
Brief Discussion of Differential/Major Teaching points of case:
Urogenital tuberculosis is the third most common form of extrapulmonary tuberculosis worldwide1, but several manifestations of the disease are often under-recognized in Western countries. As a result, it is frequently misdiagnosed as advanced ovarian malignancy or pelvic inflammatory disease. In addition, surgeons are often not aware of the clinical presentation of this disease. In women of reproductive age, tuberculosis remains the third largest cause of death globally2.
Twenty-eight cases of abdominopelvic tuberculosis mimicking advanced ovarian malignancy or pelvic inflammatory disease were described in one of the largest case series published to date on this topic3. The mean age of the women was 38.2 ± 11 years, and the most common complaints or findings were pelvic mass (75%), ascites (71%), and fevers or night sweats (46%). All 28 patients had elevated serum CA-125 levels. In another case and literature review by Yates et al.4, the presentation of a 36-year-old Filipino female living in Hawaii who presented with vague abdominal pain, fevers and a 23-pound weight loss was described. On further work up, she was found to have a 14-centimeter complex cystic pelvic mass thought to be an ovarian malignancy. Exploratory laparotomy was performed in this case, which revealed vigorous inflammatory exudate and dense adhesions. The mass itself was found to contain copious purulent material on excision, and acid-fast bacilli cultures returned positive four weeks later for M. tuberculosis.
One final unique aspect of our patient’s case was recognizing the clear stigma that still exists for tuberculosis patients, particularly in foreign-born individuals from endemic countries. This has been well described in the literature. One review by Courtwright & Turner5 examined 99 articles mostly published in Asia, the Pacific Islands and Africa, and concluded that the leading cause of stigmatization is the perceived contagiousness of tuberculosis. In countries with a high prevalence of human immunodeficiency virus (HIV), the link between the two diseases also strongly contributed to stigmatization. Other factors included the association of tuberculosis with malnutrition, poverty and low social class. Other studies have also reported a gender-specific stigmatization, with women in endemic nations reporting lower overall quality of life and lower quality of life in regards to social domains, compared to men6.
In order to ensure all patients seek timely medical treatment and achieve the most favorable quality of life, further efforts need to be made worldwide to reduce the stigmatization of tuberculosis patients.
Enter list, including the PubMed identification number, which can be found at www.pubmed.gov or http://www.ncbi.nlm.nih.gov/pubmed/.
- Figueiredo AA, Lucon AM, Srougi M. Urogenital tuberculosis. Microbiol Spectr 2017; 5. PMID: 28087922.
- Geneva, Switzerland: WHO; 2013. World Health Organization. Global Tuberculosis Report 2013. WHO/HTM/TB/2013.11; pp. 12–13.
- Liu Q, Zhang Q, Guan Q, Xu JF, Shi QL. Abdominopelvic tuberculosis mimicking advanced ovarian cancer and pelvic inflammatory disease: a series of 28 female cases. Arch Gynecol Obstet 2014; 289(3):623-9. PMID: 24100800.
- Yates JA, Collis OA, Sueblinvong T, Collis TK. Red snappers and red herrings: pelvic tuberculosis causing elevated CA 125 and mimicking advanced ovarian cancer. A case report and literature review. Hawaii J Med Public Health 2017; 76(8)220-4. PMID: 28808611.
- Courtwright A & Turner AN. Tuberculosis and stigmatization: pathways and interventions. Public Health Rep 2010; 125(Suppl 4):34-42. PMID: 20626191.
- The WHO QOL Group. What quality of life? World Health Organization Quality of Life Assessment. World Health Forum. 1996; 17(4):354-6. PMID: 9060228.
Figure #, location of image, type of image, legend
- Initial physical exam finding of significantly distended abdomen with firm, palpable, non-tender mass. See below.
- Sagittal section of initial computed tomography scan of abdomen/pelvis, revealing large, 23-cm diameter heterogeneous mass. See below. This is the most representative image of the case.
- Three acid-fast bacilli within granulomas were found on pathology review of the third biopsy specimen. See below.
J. H. Malenfant,
C. Tymchuk, None