Pelvic tuberculosis: a forgotten diagnosis - case report

Abstract

We present a case of a 14-year-old girl, Bacillus Calmette-Guérin (BCG) vaccinated, who presented with vague symptoms of abdominal pain, weight loss, and fatigue. Imaging studies revealed a pelvic mass, later found to be pelvic tuberculosis, a rare diagnosis to consider at this age. The diagnostic approach was difficult, since all investigations pointed strongly to a malignancy, from clinical, imaging (ultrasound and magnetic resonance), laboratory (elevated CA-125), and even macroscopic findings at laparotomy. Histopathology was the first hint (noncaseous granulomata), but the ultimate documentation of Mycobacterium tuberculosis relied on a persistent clinical suspicion, despite contradicting results. Surgical approach could have been mutilating, with irreversible consequences, considering it was a girl with a long reproductive life ahead. Tuberculosis is still a great masquerade, especially the extrapulmonary forms, and although infrequently seen at this age, it should thus be considered in the differential diagnosis of complex pelvic masses in order to avoid surgical iatrogeny/morbidity.

Keywords: Adnexal mass; Ovarian carcinoma; Pelvic MR; Pelvic tuberculosis; Pelvic ultrasound.

Fig. 1

Ultrasound of the pelvis showing a complex lesion, predominantly cystic, centered in the right adnexal area (a). It appears to be encapsulated with defined margins. There are multiple thin septa and an apparent solid component in a gravity-dependent location, which exhibited some vascularity in Color Doppler study (b).

Fig. 2

Ultrasound of the right iliac fossa showing associated ileal bowel wall (a) and peritoneal thickening (c) with inflammatory features (Color Doppler signal in b and c). MR image of the corresponding area (d) depicts the thickened ileal bowel loops adjacent to the lesion.

Fig. 3

MR images of the pelvic lesion. (a) Axial T2-weighted image of the complex lesion, with high signal intensity and some thin septa. (b) Axial T1-weighted image does not show areas of hyperintensity. (c) Axial contrast-enhanced T1-weighted image with fat suppression exhibits prominent enhancement of the lesion's pseudocapsule and peritoneum. (d) Subtraction image does not document any enhancing solid component within the mass.

Fig. 4

(a) Chest radiograph shows a right loculated pleural effusion. (b, c) Corresponding ultrasound showing a predominantly anechogenic effusion with some thin septa (b). A large pouch of loculated pleural fluid (c), with 96 × 45 mm, shows that the fluid is clear despite the overall complex nature of the effusion.

Fig. 5

Pelvic ultrasound, 8 months after antibacillary therapy showing almost complete regression of the lesion, with a residual 65 mm biloculated lesion.