Female genital tuberculosis is relatively rare and difficult to diagnose. Often it is mistaken for ovarian malignancy. We report a case of a young immigrant woman with acute abdominal pain.
Female genital tuberculosis is uncommon in developed countries, although an increased incidence has been noted in patients with acquired immunodeficiency syndrome and in immigrants from countries with endemic tuberculosis. Diagnosis is notoriously difficult. Clinical signs are nonspecific, as are computed tomography (CT) and ultrasound images, and there are no specific laboratory tests or biochemical markers. Initial presentation usually consists of infertility, chronic pain, or menstrual irregularities. Often it is misdiagnosed as ovarian malignancy. We present a case of female genital tuberculosis that presented as an acute abdomen.
A 24-year-old nulliparous woman presented to the emergency department with 3 weeks of left upper and lower abdominal pain. The pain had suddenly become severe with concomitant vomiting. Her medical history was uneventful. She denied previous surgery or amenorrhea. She was a Mexican-born immigrant who came to United States at 21 years of age. She had never had a purified protein derivative test. Her family history was unremarkable.
Physical examination revealed normal vital signs, clear lungs, and mild diffuse left abdominal tenderness. The vaginal examination revealed a normal-sized, retroverted uterus displaced slightly to the right, an enlarged tender left adnexa, no cervical motion tenderness, and a closed cervical os with no vaginal bleeding. Laboratory evaluation showed negative serum human chorionic gonadotropin level, normal complete blood cell count, Chem 7, and urinalysis. Tumor markers showed an extremely elevated cancer antigen (CA)-125 level (2567.6 U/mL) with normal CA 19-9, carcinoembryonic antigen, and alpha-feto-protein levels. Transabdominal and transvaginal ultrasound scanning revealed a uterus that was displaced to the right by a complex, heterogeneous, well-encapsulated left adnexal mass, and free pelvic fluid. Duplex Doppler scans demonstrated intrinsic ovarian blood flow, although a detorsed left ovary could not be ruled out. An abdominopelvic contrast spiral CT scan revealed a 9 × 9 cm left adnexal mass, a multiloculated fluid-filled mass with thickened walls, areas of soft tissue density, and possible internal bleeding ( Figure 1 ).
Because of the sudden increase of abdominal pain, the patient was taken to surgery for emergent diagnostic laparoscopy in the early hours of the morning. Entering the abdomen through laparoscope revealed distorted pelvic structures. The normal anatomic relations of uterus ovaries and fallopian tubes were obliterated. The left tube appeared to be distended ( Figure 2 ). There were extensive millet seedings of the entire parietal peritoneal wall; seedings on the liver, omentum, and pelvic organs were noted. Millet seed particles were very small (<0.5 cm); no seeds were ≥1 cm. They were pale white in color with extensive distribution on parietal peritoneum, liver, omentum, and pelvic structure. Omentum was felt with a blunt probe and believed to be of normal consistency, unlike the solid omentum cake that is normally felt in extensive malignancy. These findings were consistent with previous cases of genital tuberculosis that had been encountered by the operator in a different country. Also, given the age of the patient, the suspicion for ovarian malignancy was low. To be certain, before an extensive debulking procedure was undertaken, multiple biopsy specimens from the pelvic organs, peritoneum, and omentum were sent in normal saline solution for frozen section and in formalin for definitive diagnosis. The pathologist reported caseous necrosis on frozen section specimen, which confirmed our suspicion of genital tuberculosis.