International Journal of Surgery Case Reports 88 (2021) 106495

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International Journal of Surgery Case Reports

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Case report

Peritoneal tuberculosis mimicking advanced ovarian cancer case report:

Laparoscopy as diagnostic modality
Sigit Purbadi a, *, Junita Indarti b, Hariyono Winarto a, Andi Darma Putra a,
Kartiwa Hadi Nuryanto a, Tofan Widya Utami a, Gilbert Elia Sotarduga a
a
Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Cipto Mangunkusumo Hospital, Jakarta, Indonesia
b
Department of Obstetrics and Gynecology, Cipto Mangunkusumo Hospital, Jakarta, Indonesia

A R T I C L E I N F O A B S T R A C T

Keywords: Introduction and importance: Peritoneal Tuberculosis is one of extrapulmonary tuberculosis that occurs in 1-2% of
Peritoneal tuberculosis patients, its incidence is higher in developing countries. It is very difficult to diagnosed and can mimic advanced
Advanced ovarian cancer ovarian cases. Making an accurate diagnosis is vital, laparoscopy is a great modality for this purpose.
Laparoscopy
Case presentation: A 36 years-old woman got referred with abdominal distention and weight loss from an internist
and digestive surgeon. The abdominal computed tomography said thickening of the stomach wall with ascites.
Ultrasound concluded the uterus, ovary, and endometrium within normal. The CA 125 levels elevated to 1200 U/
mL and the complete blood count was normal. We were making diagnosis of peritoneal tuberculosis, peritoneal
carcinomatosis, and advanced ovarian cancer. We did the diagnostic laparoscopic and taking a biopsy sample,
ascites with peritoneal carcinomatosis and omental cake were found, the peritoneal cavity was covered by
miliary nodules. Histopathology results concluded peritoneal tuberculosis without malignancy signs. The patient
was treated with tuberculosis drugs. The follow-up evaluations show significant clinical improvement.
Clinical discussion: When facing patients with massive ascites and elevated CA 125 without any ovary enlarge­
ment, a gynecologist should think that it may be a peritoneal TB case with peritoneal carcinomatosis and advance
ovarian cancer possibility as differential diagnosis especially in developing countries. An exact diagnosis can be
made using laparoscopy and histopathology examination.
Conclusion: Laparoscopy is the best modality to differentiate between peritoneal tuberculosis, peritoneal carci­
nomatosis, and advance ovarian cancer. The benefits are direct visualization and could take a biopsy for his­
tology examination.

1. Introduction should think that TB cases have a very high incidence in developing
countries. The World Health Organization (WHO) estimated 9.4 million
Peritoneal Tuberculosis (TB) is one of extrapulmonary tuberculosis, cases of TB globally in 2009, with most of the cases coming from
which predominantly involves the omentum, intestinal tract, liver, developing countries [5].
spleen, or female genital tract in addition to the parietal and visceral Treatment and outcome of peritoneal TB and advanced ovarian
peritoneum [1]. It occurs in 1-2% of patients with pulmonary TB due to cancer are very different, peritoneal TB could be treated medically with
reactivation latent tuberculous foci in the peritoneum and hematoge­ an anti-tuberculosis drug, and it's curable. In contrast, advanced ovarian
nous spread from a primary disease in the lung. This extrapulmonary TB cancer must be treated by debulking surgery followed by cytotoxic
is very difficult to diagnose due to its non-specific signs and symptoms, medications and poor outcomes [6]. Careful examination and diagnosis
which sometimes leads to gynecological oncology diagnoses like are needed to differentiate this kind of case to avoid inappropriate
advanced ovarian carcinoma [2,3]. These non-specific symptoms of the treatment.
disease like abdominal or pelvis symptoms with masses, ascites, and Indonesia is one of the developing countries, the high incidence of TB
elevated CA 125 levels can mimic the advanced ovarian cancer cases, should be an awareness for the physician, obstetric gynecologist, and
and sometimes we can be confused with each other [4]. However, we oncology gynecologist to suspect peritoneal TB as a diagnosis for

* Corresponding author.
E-mail address: [email protected] (S. Purbadi).

https://doi.org/10.1016/j.ijscr.2021.106495
Received 31 August 2021; Received in revised form 6 October 2021; Accepted 7 October 2021
Available online 12 October 2021
2210-2612/© 2021 The Authors. Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
S. Purbadi et al. International Journal of Surgery Case Reports 88 (2021) 106495

abdominal masses or differential diagnosis for ovarian cancer suspect Langhans cells and concluded that it was peritoneal tuberculosis without
cases. We present our experience using laparoscopy as a diagnostic malignancy sign (Fig. 2).
modality to accurately diagnose peritoneal TB which mimics advanced From the examination results, we multidisciplinary with the internist
ovarian cancer. treated the patient using tuberculosis drugs for the disease, and doing
the one-month rectal sonography follow-up to evaluate the peritoneum
2. Case description and omentum. The first-month follow-up showed that the ascites fluid
reduced to 100–200 cc in the Douglas cavity, and the third-month rectal
A 36-years-old Asian woman presented with an eight-week history of sonography follow-up result said that no ascites were found anymore,
abdominal distention, decreased appetite with nausea, no fever or and the nausea symptom disappeared. The patient is still doing the one-
vomiting appeared, and no irregular menstrual cycle symptom was month follow-up to evaluate the medication clinically, imaging, and
found. She had lost 4 kg over three months. Due to the worsening laboratory work-up.
symptoms, she went to an internist for a medical check-up. She got
treated with anti-nausea drugs by the internist for a month, but there is Timeline
no significant improvement, and the abdominal got bigger.
Then she searches for another opinion, so she went to a digestive Date Information
surgeon. The doctor did the computed tomography scan. The abdominal June 2019 Abdominal distention, decreased appetite, weight loss.
CT-Scan said thickening of the stomach wall with widely loculated as­ September 2019 Treated by the internist.
cites in all parts of the abdominal quadrant and multiple lymphade­ November 1st Her stomach got bigger, she consulted this complaint to the
2019 digestive surgeon. The abdominal CT-Scan showed thickening
nopathies on the mid essential quadrant. The chest CT-Scan said the
of the stomach wall with widely loculated ascites in all parts of
“tree in bud” sign with solid nodule and pleural effusion duplex in the the abdominal quadrant with multiple lymphadenopathies.
left lung. The first ultrasound results said ascites, pleural effusion, and Chest CT showed a “tree in bud sign” with solid nodule and
left ovarian tumor suspect. From the results, the doctor then referred the pleural effusion. The first ultrasound said ascites, pleural
patient to us. On physical examination, we found abdominal distention effusion, and left ovarian tumor suspect.
November 12th Referred to gynecology-oncologist. Abdominal ultrasound
without tenderness. Our abdominal ultrasonography concluded uterus, 2019 concluded uterus, ovary, and endometrium were normal. No
ovary, and endometrium were normal, with no fluid appearance on fluid in the Douglas cavity. Laboratory showed CA 125 levels
Douglas cavity. Laboratory data showed blood hemoglobin 13.0 g/dL elevated to 1200 U/mL.
and CA 125 levels elevated to 1200 U/mL (normal range <35 U/mL). November 15th Diagnostic laparoscopy found 4 l of ascites with peritoneal
2019 carcinomatosis and omental cake. Uterus, both ovaries, and tube
The liver and kidney function tests were normal. We made a hypothesis
were normal. All peritoneal cavity was covered by miliary
that massive ascites with elevated CA 125 may be caused by peritoneal nodules. A biopsy sample was taken.
tuberculosis, peritoneal carcinomatosis, or advanced ovarian cancer. November 23rd Histopathology results from the biopsy concluded it was
The gold standard for diagnosis of these cases should be based on his­ 2019 peritoneal tuberculosis without malignancy signs. Patient
topathology examination, so we suggested the patient undergo diag­ treated with tuberculosis drugs.
December 2019 Ultrasound examination found ascites fluid reduced to 100–200
nostic laparoscopic to confirm the diagnosis and the patient agreed
cc in the Douglas cavity.
(Fig. 1). March 2020 The rectal sonography follow-up result said that no ascites were
In the laparoscopic view, we found 4 L of ascites with peritoneal found anymore, and the nausea symptom disappeared.
carcinomatosis and omental cake, the uterus remains normal, both
ovarium and tube also normal, but all peritoneal cavity covered by
milliary nodule. We took a sample biopsy from the nodular lesion on the
anterior abdominal wall peritoneal surface and omentum. The sample 3. Discussion
got referred to the pathologic-anatomy department for a histopathology
examination. The results said there are groups of multinucleated Datia When gynecologists facing patients with massive ascites and
elevated CA 125 without any ovary enlargement, which may be indi­
cated for malignancy, the gynecologist should think that it may be a
peritoneal TB case with peritoneal carcinomatosis and advance ovarian
cancer possibility as differential diagnosis. The concept of ascites for­
mation was due to blockage of peritoneal circulation in these cases may
be causes of the nodule. The massive volume of ascites suggests that the
blocking process is comprehensive.
Peritoneal TB is one extrapulmonary which is rare and difficult to
diagnose, accounting for 1% - 2% of all tuberculosis cases [2]. Tuber­
culosis is a major health problem in a developing country, WHO re­
ported an estimated 9.4 million cases of TB globally in 2009, and most of
the cases were from developing countries [5]. The mechanism of peri­
toneal TB may be the hematogenous spread of Mycobacterium tubercu­
losis to the abdominal cavity from a pulmonary infection. Usually, the
primary focus in the lungs heal completely, and no clinical or radio­
logical sign is detected [3,7]. Diagnosing peritoneal TB may be chal­
lenging for physicians and obstetric-gynecologist because of non-
specific clinical and laboratory findings. Patients may present similar
signs and symptoms to ovarian cancer or peritoneal carcinomatoses, and
sometimes they can be confusing (Fig. 3).
One study about peritoneal TB said that abdominal pain and
distention were two signs and symptoms which mostly appear from
physical examination with the percentage of 70% and 65%, from the
Fig. 1. Abdominal CT-scan showed thickening of stomach wall with widely laboratory, we got 80% of subjects present elevated CA-125 levels more
loculated ascites. than 35 IU/mL with 75% was more than 100 IU/mL, and the average

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S. Purbadi et al. International Journal of Surgery Case Reports 88 (2021) 106495

Fig. 2. Laparoscopic view showed ascites with peritoneal nodules.

Fig. 3. Differential diagnosis table.

level was 289 ± 186.2 IU/mL, the imaging examination using chest x- latent tuberculous infection and were not intended for active tubercu­
ray said only 25% subjects had abnormality appearance [4]. losis, which is a microbiological diagnosis [14].
On the other hand, a recent study also supports the most significant Gynecologists could also use fine needle aspiration cytology (FNAC)
and symptoms we found in the patient were abdominal pain and or fine-needle aspiration biopsy (FNAB) on the involved area for diag­
distention with 81.3% of cases. In this study, the imaging examination nostic matters. Image-directed FNAC is considered a safe, reliable, and
using ultrasound, CT-Scan, and Magnetic Resonance Imaging (MRI) accurate method for ovarian mass diagnosis, but it has been limited
concluded that ascites were the most findings with all patients (100%) because of malignancy spreading risk [7,15]. Tissue biopsy is the most
present with ascites. The omental and peritoneal thickening was the sensitive and specific diagnostic procedure for abdominopelvic TB and
second most findings in the imaging examination [6]. From these two may be obtained by laparotomy or laparoscopy. However, sometimes
studies, we can conclude signs and symptoms may appear in cases that abdominal TB can be diagnosed instantly when small tubercles (milia)
we must be aware of peritoneal TB. In addition, we must be more aware are observed on the peritoneum [16]. Microscopically, peritoneal TB
of this sign in developing countries where the incidence of tuberculosis defines by numerous, large, confluent granulomas composed of epithe­
is still high. In our cases, we found that the patient fulfills most of the lioid cells, with a peripheral zone of lymphocytes, and Langhan's giant
signs and symptoms and epidemiology included. That's why we highly cell with central caseous necrosis like we found in our cases [17].
suspected peritoneal TB as diagnosed with peritoneal carcinomatoses
and advanced ovarian cancer as the differential diagnosis. To confirm 4. Conclusion
the diagnosis, we also did the diagnostic laparoscopy to take samples for
a histopathology examination. We know that laparoscopic tissue biopsy Clinicians must consider this important differential diagnosis of
is a safe and accurate method of diagnosis with sensitivity above 80%, tuberculosis, particularly in high TB incidence areas and developing
especially with ascites present [8,9]. countries. It is necessary to accurately diagnose lower abdominal ab­
Another examination that we can use to detect tuberculosis is normality like this case because of the difference in peritoneal TB and
Interferon-gamma release assays (IGRA) and tuberculin skin test (TST). ovarian cancer therapy. The peritoneal TB can be treated by tuberculosis
IGRA is in vitro blood tests of cell-mediated immune response which drugs only, whereas ovarian cancer must be treated by operative pro­
measure T cell release of interferon-gamma (IFN-γ) [10]. IGRA are cedure and, in some cases, with chemotherapy. By making an accurate
preferred over TST in conditions where patients received BCG, and TST diagnosis, major unnecessary surgery can be avoided using minimally
is preferred over IGRA for testing children less than five years old ac­ invasive methods pre-operatively.
cording to Centers for Disease Control (CDC) 2010 guidelines [11]. One Laparoscopy is the best modality to differentiate between peritoneal
study shows that IGRA had a sensitivity of 91,18% and a specificity of tuberculosis, peritoneal carcinomatosis, and advanced ovarian cancer.
83,33% with an accuracy of 90% for detecting TB, whereas TST had a The benefits of laparoscopy are direct visualization and could take a
sensitivity of 76,47%, specificity 66,67%, and accuracy of 75% [12]. biopsy for histology examination. We should not rush into laparotomy
Some previous studies also support these results concluding IGRAs have for this kind of case, laparotomy would be an inappropriate procedure.
been shown to have superior sensitivity and specificity than TST
[13,14]. IGRA were explicitly designed to replace TST in diagnosing

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S. Purbadi et al. International Journal of Surgery Case Reports 88 (2021) 106495

5. Patient's perspective CRediT authorship contribution statement

From June until September 2019, I started to feel that my stomach Sigit Purbadi: conceptualization, methodology, resources, supervi­
got bigger, I felt nauseous and my weight get loss. My stomach got bigger sion. Sigit Purbadi, Gilbert Elia Sotarduga: writing-original draft prep­
every week and I decided to check myself to the internist. I got some aration, investigation, visualization, writing-review and editing. Sigit
medicines for a month, but no significant improvement. I decided to go Purbadi, Junita Indarti, Hariyono Winarto, Andi Darma Putra, Kartiwa
to a digestive surgeon to consult my grievance because the nauseous get Hadi Nuryanto, Tofan Widya Utami: supervision, data curation, editing.
worsen and my stomach still getting bigger. The surgeon did some im­
aging examinations like ultrasound and CT-Scan. The results concluded Declaration of competing interest
that my stomach wall thickened, there is a mass on my ovary, and also
some problems in my lungs. I was worried that it could be a malignant The authors declare that we have no financial or personal relation­
ovary mass even though I never had any history of malignancy in my ship that may have inappropriately influenced us in writing this article.
family. I got referred to the gynecologist for more advanced evaluation. I
was then going through further evaluation to confirm the diagnosis with References
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Guarantor

Sigit Purbadi.