{"paper_id":"60128bd0-a6ff-4b9c-8a02-a51fccd2da50","body_text":"Female genital tuberculosis (TB), following\nlymphatic tuberculosis, is the second most common\nextra pulmonary manifestation of tuberculosis\n( 1 ).\nSigns and symptoms of pelvic TB may be diverse\nand nonspecific, including chronic lower\nabdominal/ pelvic pain, abdominal/pelvic masses,\nanorexia, weight loss, fever, abnormal uterine\nbleeding and infertility. Moreover, an elevated\nserum CA125 level, leukocytosis, and anemia\nmay also be detected in patients having genital\ntuberculosis ( 2 ,  3 ). Female genital TB occurs in\nrelatively young females in the reproductive age\ngroup ( 4 ). Hatami’s study showed that the most\ncommonly affected age group is in range of 26-\n30 ( 5 ).\nWe report a case of a 25-year-old woman with genital\ntuberculosis mimicking a uterine leiomyoma.\n\nA 25-year-old Iranian G2P1Ab1L1 woman was\nadmitted with a 4 month history of weight loss,\nweakness, anorexia and dull abdominal pain in the\nhypogastria and left lower quadrant occasionally\nradiating to the lumbar region. She had a history of\none abortion and two operations, cesarean section\nand appendectomy.\nThere was no history of infertility, abnormal\nuterine bleeding, dysmenorrhea, dyspareunia,\nfever, cough, dyspnea, nausea and vomiting,\nurinary or gastrointestinal complications. Her\nmedical and family history was unremarkable.\nThe patient was not infertile and her contraception\nwas withdrawal. Furthermore, the patient\nhad also received her childhood bacille Calmette-\nGuerin (BCG) vaccination. The patient\nwas pale and in her physical examination, we\nfound only a mild to moderate abdominal tenderness\nin the left lower quadrant and hypogastric\nregion. On further examination, a normal\nsize mid-position uterus with a 6-7 cm palpable\nmass posterior to the uterus was detected, in\nwhich the left ovary was impossible to be detect.\nThe right ovary was palpable and cervical\nmotion tenderness was negative.\nLaboratory tests showed only a mild anemia\n(Hb=10.5 mg/dL) and the other hematologic,\nbiochemical, viral and tumor markers [including\ncancer antigen (CA)-125, alpha-feto-protein,\ncarbohydrate antigen 19-9, carcinoembryonic\nantigen (CEA), and lactate dehydrogenase\n(LDH)] were normal. Furthermore, radiologic\ninvestigations of the chest and lumbar spine\nwere also normal. HIV testing was negative in\nthis patient. Furthermore, radiologic investigations\nof the chest and lumbar spine were also\nnormal.\nAbdominal and vaginal ultrasonography\nshowed the right ovary and uterus to have a\nnormal size and shape. However, there was a\nheterogenic solid mass (110 cm ×64 cm ×8.7\ncm) lying posteriorly between the uterus and\nleft ovary ( Fig 1 ). The ultrasonographic image\nwith standard view was impossible due to frozen\npelvic. The vascular pattern of the mass was\ndominant, only having a simple cyst 2 cm ×3\ncm in dimension. The hypoechoic pattern in the\nmass was suspicious for degenerated leiomyoma.\nThere was no free fluid found in the abdominopelvic\ncavity. Because of abdominal pain, an\nexploratory laparotomy was performed.\nDuring the procedure, no seeding or ascites\nwere found. However, there were severe adhesions\namong the bowel loops, omentum, dilated\nfallopian tubes and uterus. A necrotic mass (7\ncm×6 cm) in the posterior wall of the uterus\nwas seen. The left dilated tube and ovary were\nadherent to the posterior wall of the uterus and\nmultiple biopsies were sent for frozen section.\nCaseous necrosis, devoid of malignant cells,\nwas seen in the biopsy of mass using hematoxylin\nand eosin staining ( Fig 2 ). Peritoneal fluid\nand sample were stained, specially using the\nZiehl-Neelsen staining technique. Peritoneal\nwashings and a number of biopsies were sent\nin for culture.\nRepresents the uterus and mass on the posterior with a hypoechoic pattern in the mass.\nRepresents the granulomatous reaction and central necrosis (×40).\nEpithelioid cells and mixtures of other cells, including epithelioid macrophages, giant cells (Langhans type giant cells in which\nthe nuclei are lined up around the periphery of the cell), lymphocytes, plasma cells, and fibroblasts, surround a central area of\nnecrosis that appears irregular, amorphous, and pink. There may be some neutrophils.\nMycobacterium tuberculosis  was visualized after\n5 weeks using Lowenstein-Jensen medium that\nconfirmed the diagnosis of genital tuberculosis.\nThe therapy was started empirically according\nto the histopathological results.\nThe patient underwent a 9 month course of quadruple\nanti-TB therapy including isoniazid [isonicotinic\nacid hydrazide (INH)], rifampicin (RFP),\nethambutol and pyrazinamide. The patient responded\nwell to the treatment and during a 2 year\nfollow-up, no relapse was detected.\n\nTB causes about 3 million deaths worldwide\neach year ( 6 ). Genital TB, following lymphatic tuberculosis,\nis the second-most common extra pulmonary\nmanifestation of tuberculosis and is more\ncommon among females ( 1 ,  7 ).\nThe clinical findings of genital TB are nonspecific,\nsome of the constitutional symptoms are\nweight loss, anorexia, sweat and fever.\nMost of the patients may be asymptomatic; however,\nthree major complaints have been reported\nwhich include infertility (65-70%), abdominal/\npelvic pain (50-55%) and menstrual abnormalities\n(20-25%) ( 2 ). Our patient did not experience infertility.\nSerum CA125 may be elevated in genital TB\n( 8 - 10 ). Therefore, it might mimic ovarian cancer,\nendometriosis, Meigs syndrome, ovarian hyperstimulation,\netc. Other serum markers have limited\nvalue and other tests, such as ultrasonography, and\ncomputed tomography may suggest ovarian malignancy,\ntuboovarian mass (TOA), ectopic pregnancies\nand leiomyomas ( 3 ).\nThe diagnosis of genital TB can be done with fine\nneedle aspiration by detecting caseous granulomas\nor acid fast bacilli in the smears ( 11 ). In 50-60%\nof genital TB, the endometrium is involved ( 3 ,  7 ).\nSimilar to the Xi’s study ( 12 ), examination of ascetic\nfluid was negative using the Ziehl-Neelsen\nstaining technique. Biopsies from the lesions via\nlaparotomy or laparoscopy can also help the diagnosis\nof genital TB. A definitive diagnosis is based\non a Ziehl-Neelsen staining for acid fast bacilli,\na positive culture, or polymerase chain reaction\n(PCR) of the  Mycobacterium-tuberculosis  gene\nwhich has a high sensitivity and specificity (82-\n86 and 95%, respectively) and its results are more rapid when compared to the culturing of the bacterium\n(2 days instead of weeks) ( 13 ). This particular\ncase was interesting in the sense that the patient\nhad only suffered from weight loss, anorexia and\nabdominal pelvic pain. All lab tests, apart from a\nmild anemia, were normal and the ultrasonography\nonly suggested a leiomyoma or ovarian tumor.\nIn conclusion, the diagnosis of genital TB should\nbe considered in all women with pelvic masses\nand constitutional symptoms and signs, especially\nin endemic areas like Iran. Consequently, medical\ntherapy is recommended for advanced genital TB.\nIf the patient does not respond to medical therapy,\na total abdominal hysterectomy with bilateral saplingo-oophorectomy is recommended.","source_license":"CC-BY-4.0","license_restricted":false}