Ovarian tuberculosis mimicking ovarian malignancy in an unvaccinated patient: A case report.

A 20-years-old woman was refereed from a provincial hospital with suspected ovarian malignancy based on clinical symptoms and imaging findings, she had no significant pathological history. Her chief complaint was a history of chronic pelvic and lumbar pain. The patient reported also an abdominal mass progressively increasing in size for the last 6 months. This was associated to constipation as well as nocturnal sweating and a significant weight loss of 4 kg in 6 months. She had no history of fever, chronic caught, pulmonary tuberculosis or contact with tuberculosis-infected person. She has not been vaccinated with the BCG. On general examination, the patient was apyretic, conscious, and hemodynamically stable with decolored conjunctiva. The physical examination reveal a solid, fixe right iliac fossa mass reaching the umbilical level, there was no heptomegaly, splenomegaly or lymphadenopathy the rest of the clinical examination was normal. Blood investigation showed a neutrophilic leucocytosis with WBCs at 14130/μl and neutrophiles at 12120/μl, She had also a microcytic hypochromic anemia with Hb at 10,5 g/dl. Renal functional test was normal. Tumor markers including CA125 were in normal range. Ultrasound reveal bilateral hydronephrosis related to a pelvic obstruction. Abdomino-pelvic CT scan shows a complex cystic formation at the abdomino-pelvic level compressing the adjacent organs and displaying the uterus anteriorly ( Fig. 1 ). Fig. 1 Axial CT scan demonstrating a huge complex mass occupying the abdomino-pelvic cavity with mass effect on the surrounding organs. Fig. 1 Axial CT scan demonstrating a huge complex mass occupying the abdomino-pelvic cavity with mass effect on the surrounding organs. With the suspicion of ovarian carcinoma, the patient undergoes an exploratory laparotomy that found out a huge masse occupying the entire pelvis and from which drains a caseous material when is dissected, it reveals also some micro nodules on the peritoneal surface that was biopsied for histopathological analysis ( Fig. 2 ). Fig. 2 Photomicrograph showing multiple epithelioid granulomas with giant epithelial cells and central caseous necrosis. Fig. 2 Photomicrograph showing multiple epithelioid granulomas with giant epithelial cells and central caseous necrosis. The patient was put under anti-TB drugs following the national TB management guidelines for which she responded well. A follow-up of two years, the patient remains in good health, and there is no recurrence detected.

Dr Harouachi Abdelhakim : Have written the article, have consulted the patient, prescribed all of the tests and prepared the patient for surgery and participated in the surgery. Dr Yassine Hamdaoui : have helped writing the article, data collection. Dr Lamyae Jabri : have helped writing the article, data collection. Pr Bouhout Tariq (oncology surgery professor): supervised the writing of manuscript.

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Ethics approval was not required for these cases report. Our institution (faculty of medicine and pharmacy Oujda Morocco) confirms that case report or case serie do not require ethics approval.

The author(s) received no financial support for the research, authorship and/or publication of this article.

Our paper is a case report; no registration was done for it.

Harouachi Abdelhakim.

Ovarian tuberculosis is a rare form of extra pulmonary TB that should be always considered in differential diagnosis of ovarian TB since they both share multiple similarities on clinical, biological and radiological levels inspecting directly the disease through surgical interventions and pathological analysis is usually needed to make an accurate diagnosis.

Despite being a treatable infectious disease, TB remains a worldwide challenge: it's one of the top 10 causes of death with Globally,1.2 million TB deaths only among HIV-negative people in 2018 and about a quarter of the world's population is infected with M. tuberculosis [ 3 ]. In Morocco TB remains endemic with more than 30,000 new cases of all forms of tuberculosis each year [ 9 ]. EPT is not an unusual form -that represent 15 % of all TB patients [ 10 ] and which seems to occur more in females [ 2 ]. For genital form the germ affects primarily the fallopian tube followed by endometrium [ 11 ] whereas in this case we report an isolated ovarian TB which is a rare presentation. Ovarian tuberculosis can occur even in the absence of previous pulmonary TB [ 12 ] as described in our case. Despite the numerous tools establishing, the diagnosis still challenging due to paucisymptomatic forms resulting in diagnostic delay as well as the non-specific symptoms that could present in other pathological conditions as ovarian tumors [ 13 ]. In our case the abdominal pain with alteration of the general status besides the ultrasound findings raise the suspicion of malignant origin and as a result the patient was referred to a surgical oncology department. For imaging, a chest X-ray will be useful in detecting a simultaneous pulmonary tuberculosis [ 14 ]. In our patient we performed a thoraco-abdomino-pelvic CT that shows no pathological features on the thoracic level. Ultrasound is not a helpful tool for making an accurate diagnosis since it shows no specific images that are similar to those found in ovarian carcinoma [ 15 ]. Abdominopelvic CT scan is useful in detecting tubo-ovarian masses [ 8 ]; however it cannot specify the underlying cause. Unlike ovarian tuberculosis, CT scan seems -in some cases- more useful in distinguishing peritoneal tuberculosis from ovarian and peritoneal carcinomatosis [ 16 ]. CA 125 is a classical marker for ovarian carcinoma [ 17 ], an elevation of this biomarker was reported in many other malignant and benign conditions as ovarian tuberculosis [ 18 ] which make this latter more difficult to distinguish from ovarian carcinoma. In our case the CA125 concentration was in normal range. CA125 could be used in monitoring response to treatment as its levels decrease to normal values under therapy [ 18 ]. In many cases ovarian tuberculosis and ovarian carcinoma have similar clinical, biological and radiological characteristics [ 19 ], this makes surgical explorations through laparoscopy or laparotomy the only way to establish a right diagnosis, by analyzing visually the macroscopic aspect of lesions which may reveal the presence of tubercles or caseous nodules that are Characteristic Findings of Female Genital Tuberculosis [ 6 ], also by using surgical specimen for bacteriological and histological analysis. In that case we choose laparotomy regarding to the size of the masse and its comprising feature as well as the high suspicion of malignant origin. Because of the paucibacillary nature of female genital tuberculosis [ 6 ], bacteriological analysis using the Ziehl-Neelsen stain or culture are mostly inconclusive [ 8 ], on the other hand molecular techniques as PCR have shown higher sensitivity and specificity in detecting FGTB than culture and histopathology [ 5 ]. Histopathological analysis of surgical specimens help in orienting the diagnosis to ovarian tuberculosis by showing suggestive lesion: granulomatous inflammation with caseous necrosis [ 20 ], also if the anatomopathological analysis doesn't show cancerous cells then ovarian carcinoma is less likely [ 21 ]. Based on national tuberculosis management guidelines, treatment of tuberculosis including the extra-pulmonary form as in our case is based on anti-TB drugs following a regimen of 6 months, with quadruple therapy (rifampicin, isoniazid, ethambutol, pyrazinamide) for the first two months, than 2 months of isoniazid and rifampicin [ 22 ]. Follow up of patient under anti-TB drugs is primordial due to their side effects that could be severe as hepatotoxicity, ototoxicity, nephrotoxicity and peripheral neuropathy [ 23 ]. The surgical treatment is indicated with high suspicion of malignancy [ 12 ] or in complicated forms as a compressive mass [ 24 ]. The major risk with female genital tuberculosis is infertility [ 25 ] which is estimated at 39 % among young women [ 13 ]; this may be due to a defective ovarian function, decreased reserve or even a complete destruction of the ovary [ 26 ]. An early diagnosis with immediate and adequate treatment as well as a prevention strategy including: vaccination with BCG at birth especially in endemic countries, improving the quality of health, direct observed therapy will reduce the risk of devastating consequences [ 9 ]. In our case the patient hasn't been vaccinated with BCG at birth, this emphasizes the importance of prevention through vaccination particularly in endemic areas [ 5 ].

Tuberculosis is a contagious infectious disease caused by mycobacterium tuberculosis which was first isolated by Robert Koch in 1882 [ 1 ], with a heavy burden on global health especially in developing countries as Morocco [ 2 ]. Although it's a treatable disease, it sill one of the main causes of death secondary to infectious disease [ 3 ]. It involves lungs at first place. Extra pulmonary tuberculosis is not an unusual form especially among women and patient at advanced age [ 2 ] in endemic areas [ 4 ], and genital TB represent 9 % of EPT [ 5 ]. The germ can reach the female genital apparatus generally through the hematogenous route from an extra genital site with lungs as a common primary site [ 6 ]. Most affected genital organs are Fallopian tubes (95 %), endometrium (50 %), and ovaries (20 %) [ 7 ].the main symptoms that Female Genital TB could present with, include infertility (45 %), pelvic pain (50 %), poor general health (25 %), and menstrual disturbances (20 %) [ 7 ]. Isolated ovarian tuberculosis is rare and usually wrongly diagnosed as an ovarian cancer due to the overlapping vague symptoms. In those situations preoperative investigation such as imagery always do not give a definitive diagnosis and as a result surgical tissue biopsy and analysis remain the only way to rule out malignancies and confirm ovarian tuberculosis [ 8 ]. This work has been reported in line with the SCARE criteria [ 27 ].

TB tuberculosis EPT extrapulmonary tuberculosis FGTB female genital tuberculosis tuberculosis extrapulmonary tuberculosis female genital tuberculosis

The authors declared no potential conflicts of interests with respect to research, authorship and/or publication of the article.