Ultrasonography and Biomarkers in the Diagnostic Evaluation of Peritoneal Tuberculosis: A Case Series Analysis

Abstract

Objectives: This study aims to describe the ultrasound findings and biomarker profiles (CA-125, HE4, CEA, ADA, and IGRA) in confirmed cases of peritoneal tuberculosis (PTB) and to discuss their relevance in clinical evaluation. Methods: This is a retrospective study utilizing data from 12 female subjects with a confirmed PTB diagnosis at Cipto Mangunkusumo Hospital and Hermina Depok Hospital between 2018 and 2023. Data were extracted from medical records. Biomarker levels were measured using standardized assays in a single accredited laboratory. Ultrasonography was performed using the Mindray Resona 7 system. Results: The mean age was 33.0 ± 9.7 years. Ultrasonography identified significant features of PTB, such as hydrosalpinx 7 (58.3%), adhesions 6 (50%), ascites 7 (58.3%), cystic/mass-like lesions 4 (33.3%), and involvement of the rectosigmoid colon and small bowel 2 (16.6%). CA-125 levels were elevated (mean: 484.25 U/mL), and HE4 was high in 41.6% of cases (mean: 66.8 pmol/L). CEA levels remained low (mean: 1.725 ng/mL), and ADA levels were elevated in all patients (mean: 45.8 U/L). IGRA testing yielded a 75% positivity rate, with one patient converting from negative to positive after a month. Conclusions: Ultrasound remains a valuable imaging modality for identifying characteristic features of PTB, particularly hydrosalpinx and ascites. Elevated CA-125 and ADA, alongside IGRA results, may support clinical suspicion and help guide diagnosis in settings where invasive procedures are limited.

Keywords: ADA; CA-125; IGRA; biomarkers; peritoneal tuberculosis; ultrasonography.

Figure 1

Pathogenesis of Peritoneal Tuberculosis. In the majority of cases, the bacteria propagate through the reactivation of tuberculosis in the lungs and disseminate to the peritoneum via the bloodstream or lymphatic system (yellow arrow). While less common, peritoneal infection can also occur via the gastrointestinal tract when individuals ingest contaminated sputum, unpasteurized milk, meats [5], and cheese [6]. The bacteria first infect the Peyer’s patches in the intestinal mucosa, and then spread to the mesenteric lymph nodes, where epithelioid tubercles form. Over the course of 2 to 4 weeks, caseous necrosis develops within these tubercles, leading to ulceration of the mucosal lining and potential infection of deeper intestinal layers. Eventually, the infection can spread to nearby lymph nodes and the peritoneum (red arrow). A rarer pathway of infection involves direct contamination of the peritoneum from a nearby infectious source, such as an abscess in the fallopian tubes [7] (green arrow).

Figure 2

Fluid accumulation with caseous degeneration in the Douglas pouch. Ov-H: Ovary—High; Ov-L: Ovary—Low.

Figure 3

(A) Fluid accumulation in Morison’s pouch and splenorenal recess; (B) Fluid resolution after one month of anti-tuberculosis drug therapy.

Figure 4

(A) Fluid accumulation in the Douglas pouch with caseous degeneration covering the uterus and rectosigmoid colon; (B) Significant reduction in fluid and caseous degeneration after one month of anti-tuberculosis drug therapy.

Figure 5

(A) Complex adhesion between the ovary and fallopian tube on the ipsilateral side, along with fluid accumulation in the peritoneal cavity; (B) Fluid and caseous degeneration decrease significantly in peritoneal cavity after one month of therapy with anti-tuberculosis drugs.

Figure 6

Formation of incomplete septa filled with complex fluid.

Figure 7

Accumulation of caseous degeneration in the endometrium characterized by a “fern-like pattern” and associated endometrial thickening.