Red Snappers and Red Herrings: Pelvic Tuberculosis Causing Elevated CA 125 and Mimicking Advanced Ovarian Cancer. A Case Report and Literature Review

Abstract

Female genital tuberculosis (FGTB) is a form of extra-pulmonary tuberculosis that has been primarily described in developing countries, where it is an important cause of infertility, ectopic pregnancy, and miscarriage. FGTB is rare in the United States and because its clinical presentation is non-specific and often insidious, FGTB may be misdiagnosed as a gynecologic malignancy or endometriosis. The tendency of tuberculosis to dramatically increase serum CA 125 levels contributes to the potential for FGTB to be mistaken for ovarian cancer in particular. We describe the case of a young woman who presented with what was initially thought to be advanced ovarian cancer but who had tuberculosis of the peritoneum, uterus, and ovaries discovered at laparotomy. This case emphasizes the importance of considering tuberculosis in the differential of any patient presenting with an abdomino-pelvic mass and an elevated CA 125 level.

Figure 1

On CT scan, a 14 cm complex cystic/solid pelvic mass (as indicated by arrow) concerning for ovarian cancer was seen. Enlarged epicardial and parasternal lymph nodes were also noted; no parenchymal lung lesions were present. The findings were suspicious for advanced ovarian cancer.

Figure 2

Innumerable pale, miliary nodules (arrows) were seen over the serosa of the small intestine and mesentery, with inflammatory, densely fibrinous adhesions throughout the pelvis. An amorphous pelvic mass encased the uterus and both ovaries.

Figure 3

Multiple caseating granulomas and Langhans giant cells were seen in biopsy specimens of the peritoneum (A) and the pelvic mass (B). Rare AFB (“red snappers”) were visible on Fite stain.

Figure 4

A culture of the patient's pelvic mass biopsy grew M. tuberculosis (MTB), shown here growing on Lowenstein-Jensen agar (A). In liquid media, “serpentine cords” of acid-fast bacilli were seen, typical of MTB (B).

Figure 5

The patient's serum CA 125 was markedly elevated shortly prior to her diagnosis of TB, and was dramatically lower after two months of treatment.