Neutrophil-Predominant Peritoneal Tuberculosis With Salpingitis Mimicking Ovarian Cancer: A Case Report

Abstract

Tuberculosis (TB) is caused by Mycobacterium tuberculosis. It is a multisystem infection, but the most common manifestation is pulmonary. TB is the leading cause of death among infectious diseases. Abdominal TB is a form of extrapulmonary TB (EPTB) that often presents nonspecifically and can result from genitourinary or hematogenous spread. We present the case of a 20-year-old Bangladeshi woman who presented with a two-month history of fever and night sweats accompanied by vomiting, tachycardia, and tachypnea. Laboratory investigations revealed elevated inflammatory markers, lactate dehydrogenase, and cancer antigen 125. QuantiFERON-TB (QIAGEN N.V., Venlo, Netherlands) was positive. An abdominal ultrasound showed free fluid throughout the abdomen. A CT scan of the abdomen revealed thickening and enhancement of the peritoneum, omental caking, and bilateral bulky ovaries measuring up to 8.5 x 5.4 cm on the right side, raising suspicion of malignancy. However, an MRI showed that the pelvic masses were, in fact, bilateral hydrosalpinx. Peritoneal analysis indicated a serum ascites albumin gradient (SAAG) of less than 1.1, suggesting peritonitis with neutrophil predominance. Acid-fast bacillus (AFB) culture of the peritoneal fluid grew M. tuberculosis. Abdominal TB and ovarian cancers can overlap in clinical presentation, especially in young female patients. Imaging may be misleading, as seen in this case. Imaging modalities may assist in the diagnosis; further exploration, particularly diagnostic laparoscopy with biopsy, is required for suspected ovarian cancer and EPTB.

Keywords: abdominal; cancer; extrapulmonary; genital; malignancy; ovarian; peritonitis; salpingitis; salpinx; tuberculosis.

Figure 1. Abdomen and pelvis CT with contrast

(a) Transverse section of the abdomen showing a significant volume of abdominopelvic free fluid collection noted in the mid-abdomen, accompanied by clustered bowel; (b) Transverse and sagittal sections of the abdomen showing omental fat stranding and nodularity anterior to the transverse colon, suggestive of omental caking (arrow); (c) Transverse and sagittal sections of the pelvis showing, at the acetabulum level, bilateral bulky ovaries measuring approximately 8.5 x 5.4 cm on the right side with multiple large follicles and 6 x 4.5 cm on the left side with multiple follicles (arrows)

Figure 2. Axial T2-weighted pelvis MRI with contrast reveals a hydrosalpinx with a thick-walled fallopian tube showing marked enhancement and restricted diffusion, indicating pyosalpinx (circle)