A 32-year-old woman was referred to the Gynecologic Oncology service with history of abdominal pain and weight loss of 10Kg in the last six months. An ultrasound performed a few days before had shown enlarged ovaries, ascites and omental and peritoneum thickening. CA125 level was 1986IU/mL (N<200IU/mL).

Considering the diagnosis of ovarian and peritoneal cancer, an exploratory laparotomy was performed. During surgery, there was no evidence of ovarian tumor, instead, diffuse nodules, edema and significant hyperemia were seen in the uterus, tubes, peritoneum and omentum (Figures 1 and 2). Intra-operative frozen section consultation showed a chronic granulomatous inflammatory process, with giant multinucleated cells. After tissue and peritoneal fluid samples collection, the abdomen was closed without any other intervention. Both, ascitic fluid Adenosine Deaminase levels and histopathological tissue analysis were suggestive of tuberculosis (Figure 3).

Staining methods searching for Alcohol and Acid Fast Bacilli and for fungi were negative (Figures 4 and 5). The patient was treated for tuberculosis with complete symptoms recovery.

Keywords: Ascites, Inflammatory disease, Ovarian cancer, Pelvic tuberculosis

The presentation of abdomino-pelvic tuberculosis simulating advanced ovarian cancer has been consistently reported in the literature [1], [2], [3], as the finding of pelvic masses, ascites and increased levels of CA 125 is common in both entities. Since the response to treatment and survival rates is totally different in the two conditions, differential diagnosis is especially important [3].

In women with echographic suspicion of an ovarian mass, a systematic analysis of signs indicative of malignancy has recently been proposed [4] and its use is expected to reduce false-positive results caused by inflammatory and infectious diseases, such as tuberculosis. When surgical intervention is necessary, the laparoscopic approach has advantages over open surgery and allows the obtaining of tissue and peritoneal fluid samples for analysis. In cases in which the diagnostic doubt arises during surgery, freezing biopsy is a priceless tool to avoid unnecessary bilateral oophorectomy.

Tuberculosis is an infectious disease with rare involvement of the genital tract, with the power to mimic other gynecological diseases, including malignant tumors. The diagnosis must combine a high index of suspicion with clinical evaluation and appropriate histopathological and microbiological investigation. If this diagnosis is suspected, it can spare patients from unnecessary surgeries.

1. Xi X, Shuang L, Dan W, et al. Diagnostic dilemma of abdominopelvic tuberculosis: A series of 20 cases. J Cancer Res Clin Oncol 2010 Dec;136(12):1839–44.   [CrossRef]   [PubMed]    
2. Koc S, Beydilli G, Tulunay G, et al. Peritoneal tuberculosis mimicking advanced ovarian cancer: A retrospective review of 22 cases. Gynecol Oncol 2006 Nov;103(2):565–9.   [CrossRef]   [PubMed]    
3. 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 Mar;289(3):623–9.   [CrossRef]   [PubMed]    
4. Timmerman D, Van Calster B, Testa A, et al. Predicting the risk of malignancy in adnexal masses based on the simple rules from the international ovarian tumor analysis group. Am J Obstet Gynecol 2016 Apr;214(4):424–37.   [CrossRef]   [PubMed]