Abstract:
Background: Tuberculosis remains a major global health concern, particularly in low- and middle-income countries where it is endemic. Although pulmonary tuberculosis is the most common presentation, extrapulmonary tuberculosis accounts for approximately 15–20% of cases, with abdominal tuberculosis representing a significant subset. Tuberculous peritonitis is characterized by chronic granulomatous inflammation of the peritoneum and often presents with nonspecific symptoms such as abdominal pain, distention, fever, weight loss, night sweats, and ascites. Elevated cancer antigen 125 (CA-125) levels and radiologic findings including peritoneal thickening, omental caking, ascites, and adnexal masses may closely resemble advanced ovarian or primary peritoneal malignancy. Consequently, diagnosis before surgery is difficult, often resulting in unnecessary exploratory procedures and delayed anti-tuberculous treatment. This case highlights the diagnostic challenge of tuberculous peritonitis and the importance of maintaining a high index of suspicion in tuberculosis-endemic regions.
Aim: To describe a case of tuberculous peritonitis initially suspected to be ovarian malignancy based on clinical, laboratory, and radiologic findings, and to emphasize the role of histopathology in establishing the diagnosis and guiding appropriate management.
Methods: A 32-year-old previously healthy woman presented with a three-month history of progressive abdominal distention, unintentional weight loss, intermittent undocumented fever, and night sweats. She denied cough, hemoptysis, previous tuberculosis treatment, or known tuberculosis exposure. Physical examination revealed a palpable firm lower abdominal mass with mild tenderness. Laboratory evaluation showed mild anemia (hemoglobin 109 g/L), while other routine investigations were unremarkable. Serum CA-125 was markedly elevated at 618 U/mL. Contrast-enhanced computed tomography of the abdomen and pelvis demonstrated a 4.2-cm complex right adnexal mass, diffuse peritoneal thickening with extensive nodularity suggestive of peritoneal carcinomatosis, moderate ascites, diffuse small bowel wall thickening, and omental involvement. Because of the high suspicion for ovarian malignancy, exploratory laparotomy with peritoneal and omental biopsies was performed. Histopathologic examination, including Ziehl–Neelsen staining, established the definitive diagnosis.
Results: Surgical exploration revealed diffuse thickening of the parietal and visceral peritoneum with multiple caseating nodules involving the peritoneal surfaces and omentum. The apparent pelvic mass originated from inflamed peritoneal and omental tissue rather than the ovaries, while both ovaries and fallopian tubes were grossly normal. Histopathology demonstrated multiple well-formed granulomas with central caseous necrosis and Langhans giant cells. Ziehl–Neelsen staining identified acid-fast bacilli, confirming tuberculous peritonitis. Standard first-line anti-tuberculous therapy with isoniazid, rifampicin, pyrazinamide, and ethambutol was initiated. The patient showed marked clinical improvement with resolution of abdominal distention and constitutional symptoms. Follow-up imaging demonstrated regression of peritoneal thickening, resolution of ascites, and disappearance of the mass-like lesion.
Conclusion: Tuberculous peritonitis should be considered in patients presenting with adnexal masses, elevated CA-125, ascites, and imaging findings suggestive of ovarian or peritoneal malignancy, particularly in tuberculosis-endemic settings. This case underscores the limitations of relying solely on imaging and tumor markers to distinguish infectious from malignant conditions. Histopathologic confirmation remains the diagnostic gold standard and should be pursued whenever feasible before extensive surgery. Early diagnosis and prompt anti-tuberculous therapy can prevent unnecessary radical procedures, reduce morbidity, and achieve favorable clinical outcomes.
Biography:
Dr. Rasheena Jainal is an Internal Medicine resident at West Metro Medical Center in Zamboanga City, Philippines. She has a strong interest in clinical research, evidence-based medicine, and academic writing, with a particular focus on gastroenterology, neurology, and complex internal medicine cases. She actively participates in local and international scientific meetings and has authored and presented research abstracts on a variety of clinical topics. Beyond clinical training, she is committed to promoting research among healthcare professionals and advancing patient-centered care through continuous learning. Dr. Jainal aspires to contribute meaningfully to medical education, research, and the improvement of healthcare delivery.
