Case report of a pelvic-peritoneal tuberculosis presenting as an adnexial mass and mimicking ovarian cancer, and a review of the literature.

A 49-year-old perimenopausal woman, gravida 7, para 5 was referrred to our gynecology clinic for the evaluation of extensive ascites. From her history we learned that she had been admitted to the rheumatology clinic with complaints of arthalgia and fatigue 2 months previously and had been given salazopyrin therapy for the past 2 months with a presumptive diagnosis of rheumatoid or infective arthritis. After 15 days of therapy she started to feel abdominal swelling and distension, had difficulty in breathing and started to feel an epigastric burning sensation. She had not experienced any gynecological complaints other than irregular menses for the past 6 months and had not experienced any weight loss for the past few months. The patient described something like a hot-flush during the nights, but there were no measured body temperatures available so it was impossible to make the discrimination between fever and hot-flush. Abdomino-pelvic CT (computerized tomography) demonstrated mild splenomegaly, lobulation of the uterine contours and hypodens lesions on the right side of the myometrium and extensive ascites in the abdomen. Transvaginal ultrasound was irrelevant except for a 25 x 31 mm pure cystic right adnexial mass. Doppler ultrasound confirmed a 26 x 22 x 26 mm right adnexial cystic mass, with no solid components and no pathological blood flows or impedence measures. Laboratory findings were all within normal ranges except for an elevated eritrocyte sedimentation rate and CA 125 (normal range is 0–35) which were 84 and 844.8 respectively. Liver function tests and viral and immunologic markers were in normal ranges or negative. On the basis of these findings we planned an exploratory laparotomy with the presumption of ovarian cancer. For this age, a chest x-ray is not a routine procedure of our clinic, therefore we did not take a chest x-ray before the operation. The day before the operation, about a month later than the first one, we performed another transvaginal ultrasound and found that the right adnexial cystic mass lesion had increased in size to 57 x 51 mm. At laparotomy, miliary deposits were seen on the hemidiaphragmatic surfaces, the surface of the liver, the peritoneal surfaces covering the abdominal walls and on the serozal surfaces of the small bowels, which were at first sight misdiagnosed as metastatic lesions of ovarian cancer. A 50 x 50 mm cystic mass originating from the right ovary and a 30 x 40 mm plaque on the mesentery of the ileum (which was thought to