Pelvic-peritoneal pseudotumoral tuberculosis with elevated CA 125 mimicking ovarian cancer: A case report.

A 49-year-old female, with no notable medical history and no history of tuberculosis exposure, seeks medical attention for abdominal bloating and abdominal pain evolving over 2 months, accompanied by fatigue, anorexia, and weight loss amounting to 6kg. Physical examination revealed a distended abdomen with dullness in the flanks, sensitivity in the left iliac fossa, and guarding upon deep palpation. A pelvic ultrasound was performed, revealing a heterogeneous, hypoechoic left adnexal mass ( Fig. 1 ). Fig. 1 A pelvic ultrasound revealing a heterogeneous, hypoechoic left adnexal mass. Fig 1 A pelvic ultrasound revealing a heterogeneous, hypoechoic left adnexal mass. An MRI was requested and revealed a heterogeneous predominantly solid left uterine-lateral mass containing areas of intermediate T2 signal with diffusion restriction. It enhanced after Gadolinium injection, measuring a maximum thickness of 45 mm. There was a substantial amount of peritoneal effusion associated with peritoneal thickening in some areas ( Fig. 2 ). This led to the conclusion of a left ovarian mass with peritoneal carcinomatosis classified as ORADS 5. Fig. 2 Pelvic MRI (A) Sagittal plane, (B) Axial plane, (C) Axial plane after Gadolinium injection) revealed a heterogeneous predominantly solid mass in the left ovary with intermediate T2 signal, enhanced after Gadolinium injection (green arrow). A significant amount of peritoneal effusion (red arrow) associated with carcinomatosis nodules (blue arrow). Fig 2 Pelvic MRI (A) Sagittal plane, (B) Axial plane, (C) Axial plane after Gadolinium injection) revealed a heterogeneous predominantly solid mass in the left ovary with intermediate T2 signal, enhanced after Gadolinium injection (green arrow). A significant amount of peritoneal effusion (red arrow) associated with carcinomatosis nodules (blue arrow). Biological analyses revealed an increase in the level of CA125 and CRP Table showing the results of biological analyzes. Analysis Value Reference value CA125 191 IU/mL < 35 CRP 48 mg/L 12g/dl Leukocyte 7370 /mm3 Between 4000 and 10000 Table showing the results of biological analyzes. The initial consideration was a diagnosis of ovarian tumor complicated by peritoneal carcinomatosis. The patient underwent exploratory laparoscopy with biopsy of the omentum and carcinomatosis nodules, revealing a granulomatous inflammation characterized by granulomas of epithelioid cells and giant cells centered around caseous necrosis. This confirmed the diagnosis of tuberculosis, with an absence of histological signs of malignancy ( Fig. 3 ). Fig. 3 Hematoxylin-Eosin-Safran (HES) staining: epithelioid and giant-cell granulomas, occasionally centered around an area of caseous necrosis. Fig 3 Hematoxylin-Eosin-Safran (HES) staining: epithelioid and giant-cell granulomas, occasionally centered around an area of caseous necrosis. The patient received a 6-month antituberculosis treatment: the first 2 months involved daily administration of a combination of 4 medications—rifampicin, isoniazid, pyrazinamide, and ethambutol—followed by a combination of 2 medications—rifampicin and isoniazid—for the remaining 4 months. Following 6 months of antitubercular treatment and with close clinical monitoring every month, the patient experienced a notable improvement with the disappearance of pelvic pain and abdominal bloating, weight gain, and normalization of CA125 levels. An MRI conducted after the treatment revealed a reduction in size of the well-defined, rounded solid mass in the left ovary, showing intermediate T2 signal, diffusion restriction, and enhancement after Gadolinium injection. The curve type was classified as ORADS 3, measuring a maximum thickness of 20 mm. There was regression of peritoneal effusion and nodular peritoneal thickening ( Fig. 4 ) Fig. 4 Pelvic MRI after treatment (A) Sagittal sequence, (B) Axial sequence, (C) Axial sequence after Gadolinium injection) showed a decrease in the size of the solid mass in the left ovary, with annular enhancement. Fig 4 Pelvic MRI after treatment (A) Sagittal sequence, (B) Axial sequence, (C) Axial sequence after Gadolinium injection) showed a decrease in the size of the solid mass in the left ovary, with annular enhancement.

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Pelvic tuberculosis is a rare condition, and a definitive diagnosis is primarily based on the histological examination of specimens obtained during laparotomy or laparoscopy. Pelvic tuberculosis is a manifestation that can mimic ovarian cancer. It is crucial to consider pelvic tuberculosis whenever dealing with a young patient from a tuberculosis-endemic region or with immunosuppression.

Tuberculosis remains a public health concern and is one of the most widespread infectious diseases worldwide, especially in developing countries. In Morocco, in 2020, the recorded number of cases was 29,018, encompassing all forms of the disease. There were 244 cases of co-infection with tuberculosis and human immunodeficiency virus (HIV) [ 1 ]. Pelvic tuberculosis, a rare form, ranks fifth among extrapulmonary forms after lymph node, osteoarticular, pleural and digestive forms. It represents 6%-10% of cases of extrapulmonary forms, It accounts for 6%-10% of cases, primarily involving the fallopian tubes, followed by cervical and endometrial involvement [ 2 ]. Pelvic tuberculosis constitutes a significant cause of morbidity, particularly leading to infertility and chronic pelvic pain. It typically affects young women aged 20 to 30 who reside in endemic areas [ 3 ]. In our case, the patient was 49 years old. The concurrent presence of pulmonary or digestive involvement can suggest this diagnosis, but it is not consistent and may be absent in 30%-50% of cases [ 4 ].Our patient did not have associated pulmonary involvement. Pelvic tuberculosis is always secondary and follows either hematogenous dissemination from an initial tuberculous focus, with an initial involvement of the fallopian tubes leading to a picture of salpingitis, from which the infection progresses to other genital organs; or contamination via the lymphatic route from pelvic lymph nodes [ 5 ]. From a clinical perspective, the symptoms are highly varied and nonspecific, which may lead to a misguided suspicion of ovarian malignancy. Indeed, pelvic pain, pelvic masses, ascites, and weight loss can be present in both pathologies. The exploration of other signs such as menstrual disturbances (dysmenorrhea, amenorrhea), digestive issues, and intermittent urinary symptoms is essential. Additionally, infertility may be indicative in 5%-10% of cases [ 6 ]. Our patient exhibited most of the symptoms, and we also initially suspected a malignant origin. On a radiological level, ultrasound, CT scans, and magnetic resonance imaging (MRI) findings are not specific, as there are no distinct signs to differentiate pelvic tuberculosis from a malignant tumor with peritoneal carcinomatosis [ 2 ]. The presence of a heterogeneous pelvic mass with a dual component, along with ascites, peritoneal thickening, and enhancement, leans towards ovarian tumor with peritoneal carcinomatosis [ 2 ]. All these signs were present in our case, which is why we initially suspected a malignant origin. Sometimes, there may be a presentation resembling bilateral hydrosalpinx with an enlarged ovary accompanied by ascites. The lesion can infiltrate neighboring fat and may even invade it, leading to fistulization with adjacent organs [ 7 ]. CA125, a marker elevated in over 80% of ovarian cancers, can also be elevated in chronic inflammatory conditions such as tuberculosis [ 7 ], pregnancy, endometriosis, pancreatitis, hepatitis, ascites, and postoperative states [ 8 ]. The CA125 level was elevated in our case. Transvaginal or transabdominal echo-guided biopsies may be suggested in cases of suspected peritoneal or pelvic tuberculosis [ 10 ]. Surgical exploration is often necessary, either through laparoscopy, which is the most reliable approach for diagnosing pelvic tuberculosis, especially for tubal, ovarian, and peritoneal involvement, or through laparotomy. The latter allows for a diagnosis in more than 97% of cases [ 9 ]. Laparoscopy with biopsy is highly valuable as it enables the diagnosis of pelvic tuberculosis in over 97% of cases, thereby avoiding laparotomy [ 10 ]. Histological examination of the biopsies or operative specimen allows for confirming the diagnosis or correcting it in cases where a tumor is suspected, revealing giant cell granulomas with specific caseous necrosis characteristic of the Koch bacillus [ 11 ]. However, the visualization of granulomas is by no means synonymous with tuberculosis and can also be observed in infections with atypical mycobacteria such as sarcoidosis, cat scratch fever, brucellosis, and in reactions to foreign bodies [ 12 ]. The presence of caseous necrosis is a major, almost specific, argument in favor of tuberculosis [ 12 ]. Treatment for pelvic tuberculosis is primarily medicinal [ 13 ]. A short-duration treatment has proven to be effective. The therapeutic regimen consists of 2 phases: an intensive phase of 2 months, involving daily administration of a 4-drug combination of rifampicin, isoniazid, pyrazinamide, and ethambutol, followed by a continuation phase of 4 months with a 2-drug combination of rifampicin and isoniazid [ 14 ]. Surgery plays a role in cases of compressive or fistulized masses to address caseous cavities or persistent adnexal masses despite well-conducted medical treatment [ 15 ]. The decrease and normalization of CA125 serum levels are correlated with the favorable progression of the disease under antibacterial treatment, making CA125 measurement a proposed element in monitoring treatment efficacy. The prognosis of pelvic tuberculosis is linked to the infertility of young women. The risk of tubo-ovarian infertility is estimated at 39% [ 16 ].

Pelvic tuberculosis, a rare form of extrapulmonary tuberculosis, is presented as a chronic infectious disease caused by Mycobacterium tuberculosis. Diagnostic challenges arise particularly when clinical presentation and imaging results strongly suggest a malignant tumor, such as an Ovarian-Adnexal Reporting and Data System (ORADS 5) lesion. Consequently, confirming the diagnosis requires a combination of clinical evaluation, imaging, and sometimes invasive procedures such as biopsy or laparoscopy. When malignancy is initially suspected, it is crucial to conduct a thorough assessment to rule out or confirm tuberculosis, as the treatment and management strategies differ significantly, potentially avoiding unnecessary aggressive surgical intervention in cases of tuberculosis.