48uep6bbphidvals|259
48uep6bbphidcol4|ID
48uep6bbph|2000F98CTab_Articles|Fulltext
The incidence of tuberculosis is increasing both in the developing as well as the developed countries. According to the World Health Organization estimates of tuberculosis burden, there were 8.3 million new cases in 2000 throughout the world and about 48 % of these were from the developing countries[1]. The incidence of tuberculosis in cancer patients is also high due to their innate compromised immunity. This predisposes them to acquiring the infection primarily or reactivation of latent tuberculosis following intensive chemotherapy very easily[2]. It is very often found in developing countries where the incidence of tuberculosis is high, that a patient getting investigated for malignancy is diagnosed to have either only tuberculosis or both tuberculosis and cancer. Clinical, radiological and laboratory findings are often similar between ovarian malignancy and abdominal tuberculosis. This presentation often creates dilemmas in establishing a definitive diagnosis particularly in centres with limited resources. Here we report and discuss such a patient which highlights this clinical problem.
Case Report
A 50 yr old lady presented with progressive abdominal distension and breathing difficulty for 3 months. It was not associated with swelling in any other part of the body (generalised edema), fever, hemoptysis, hematemesis or malena. She was a known case of schizoaffective disorder on medications. General examination and examination of respiratory and cardiovascular systems were unremarkable. Abdominal examination revealed moderate ascites and vaginal examination suggested an ill defined right adnexal mass. CA 125 was moderately elevated (154 U/ml), While CEA (6.97 ng/ml) and CA 19.9 (17.3 U/ml) levels were with in normal laboratory range. Based on the clinical findings and marginally elevated CA 125, a clinical diagnosis of ovarian malignancy was made. However, examination of ascitic fluid revealed exudative fluid with predominant lymphocytosis. No acid fast bacilli were detected on smear examination or culture. Computed tomography of the abdomen did not reveal any abnormal mass lesions in the ovary except for mildly bulky right ovary for the age. It confirmed moderate ascites, moderate right and minimal left pleural effusion. Diffuse omental thickening up to 10mm with multiple small nodules was noted. Multiple small nodules were found in bilateral lung bases. USG guided omental biopsy revealed caseating granulomatous inflammation consistent with tuberculosis. The patient was subsequently started on DOTS antituberculous regimen.
Discussion
Patients presenting with ascites and adnexal mass often pose a diagnostic difficulty in oncology clinics especially in developing countries where the prevalence of both latent and active tuberculosis is very high. A strong suspicion of peritoneal tuberculosis should be made in such situations especially in endemic areas where there seems to be clustering of extra pulmonary tuberculosis among women[3]. Family history of tuberculosis or history of fever, weight loss may aid in diagnosis. Chest X-ray is often negative for tuberculosis and imaging may show omental and mesenteric thickening and pelvic masses[4]. CT scan of the abdomen may to a certain extent help distinguish between tuberculous peritonitis and malignancy as suggested by Jiang et al[5]. CA 125 is not a sensitive tumor marker in such situations as it may be elevated in tuberculosis, hepatitis, pancreatitis and endometriosis[6]. Recently various immunological and molecular diagnostics techniques are in the pipeline like phage assay, rapid culture, nucleic acid amplification[7] and IFN-a (interferon-gamma) assay[8] for early detection of tuberculosis. Ascitic fluid polymerase chain reaction for mycobacterium may prove to be an easy and sensitive test for abdominal tuberculosis in future[9]. But these tests are being tested in immunocompetent hosts; hence the validity of such tests in an immunocompromised hosts likes the one having cancer is unknown. While various authors have described similar case presentations and they had decided to do a laparoscopic biopsy or an exploratory laparotomy and thus conform the diagnosis[10,11]. This may be a more definitive way of assessing and obtaining a tissue for diagnosis. But this needs a sophisticated infrastructure and a skilled surgeon to do the procedure. This is still not a widely available option in developing countries where this type of clinical condition is highly prevalent.Ultrasound imaging is the most readily available economical equipment in the majority of health centres in developing country[12]. Therefore in our opinion, where minimally invasive diagnostic procedures are not feasible and early diagnosis by immunological and molecular assays are awaiting validation, Ultrasound guided omental biopsy may be more practical and useful in achieving a definitive histological diagnosis in such situations in developing countries.
Reference
1. Corbett EL, Watt CJ, Walker N, Maher D, Williams BG, Raviglione MC, et al. The growing burden of tuberculosis: global trends and interactions with the HIV epidemic. Arch Intern Med. 2003;163:1009–21.
2. Ito K, Fujimori M, Shingu K, Hama Y, Kanai T, Koyama H, et al. Pulmonary tuberculosis in a patient receiving intensive chemotherapy for metastatic breast cancer. Breast J. 2005;11:87–8.
3. Rasolofo Razanamparany V, Menard D, Auregan G, Gicquel B, Chanteau S. Extrapulmonary and pulmonary tuberculosis in antananarivo (madagascar): high clustering rate in female patients. J Clin Microbiol. 2002;40:3964–9.
4. Chow TW, Lim BK, Vallipuram S. The masquerades of female pelvic tuberculosis: case reports and review of literature on clinical presentations and diagnosis. J Obstet Gynaecol Res. 2002;28:203–10.
5. Jiang LX, Dai JR. Peritoneal tuberculosis mimicking advanced ovarian carcinoma: distinction based on CT findings. Zhonghua Zhong Liu Za Zhi. 2004;26:122–5.
6. Bagga R, Suri V, Malhotra S, Patel Y. Peritoneal tuberculosis mimicking advanced ovarian cancer. Int J Gynaecol Obstet. 2005;90:242–4.
7. Perkins MD, Roscigno G, Zumla A. Progress towards improved tuberculosis diagnostics for developing countries. Lancet. 2006;367:942–3.
8. Pai M, Riley LW, Colford JM Jr. Interferon-gamma assays in the immunodiagnosis of tuberculosis: a systematic review. Lancet Infect Dis. 2004;4:761–76.
9. WangYC, Lu JJ, Chen CH, Peng YJ, Yu MH. Peritoneal tuberculosis mimicking ovarian cancer can be diagnosed by polymerase chain reaction: a case report. Gynecol Oncol. 2005;97:961–3.
10. Piura B, Rabinovich A, Leron E, Yanai-Inbar I, Mazor M. Peritoneal tuberculosis mimicking ovarian carcinoma with ascites and elevated serum CA-125: case report and review of literature. Eur J Gynaecol Oncol. 2002;23:120–2.
11. 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.
12. Ali QM, Roth J, Abdel-Rahim IM, Franke D, Kardorff R, Schweisfurth H, et al. Cost saving with ultrasonography in a developing country district hospital. East Afr Med J. 1999;76:272–4.