An 18-Year-Old With Nausea and Increased Abdominal Girth

Michel E. Rivlin, MD

Disclosures

January 26, 2016

Physical Examination and Workup

On physical examination, she is 58 inches (147.32 cm) in height and weighs 115 lb (52.2 kg). Her vital signs include an oral temperature of 99.5° F (37.5° C), a pulse rate of 106 beats/min, and a blood pressure of 98/61 mm Hg. The patient appears to be in no acute distress. The examination of her chest, including auscultation of her heart and lungs, reveals no abnormalities. The peripheral pulses are palpable.

The examination of her head and neck, as well as the neurologic examination, are normal. Her abdomen appears visibly distended and there is some degree of lower abdominal tenderness, but no guarding or rigidity is noted. No hepatomegaly or splenomegaly is found. The abdomen is dull to percussion and marked ascites is noted, with shifting dullness. A large, doughy mass is found in the lower abdomen, which is tender on deep palpation. The mass is immobile, firm, does not move with breathing movements, and is nonpulsatile. The overlying skin is normal, with no erythema, pallor, or venous distention. The mass extends from the pelvis in the midline towards the umbilicus. On rectovaginal examination, the mass is found to be filling the pelvis to a size similar to that of a 20-week pregnancy. No evidence of cervical discharge is present, and the vulva, vagina, and cervix appear normal. The rest of the physical examination is normal.

Significant laboratory analyses include a hematocrit of 26.7% (0.267), a platelet count of 51 × 103/μL (51 × 109/L), and a white blood cell (WBC) count of 9 × 103/μL (9 × 109/L). Her carcinoembryonic antigen (CEA) level is less than 1 ng/mL (1 μg/L; normal range, 0-10 ng/mL), her human chorionic gonadotropin (hCG) value is < 5 mIU/mL (5 IU/L; normal range for a nonpregnant woman, < 5 mIU/mL), her alpha-fetoprotein (AFP) level is 0.8 ng/mL (0.8 μg/L; normal range, 0-10 ng/mL), her lactate dehydrogenase (LDH) measurement is 534 U/L (normal range, 259-613 U/L), and her cancer antigen (CA) 125 level is 509 U/mL (509 kU/L; normal range, 0-35 U/mL). Her hepatic function tests are normal.

Figure 1.

Figure 2.

Radiographs of the chest and an ECG are ordered and are found to be normal. Pelvic ultrasonography indicates a normal-sized uterus and endometrial stripe; it also shows a complex, midline pelvic mass of 11 × 9 cm in size, with both solid and cystic components (Figure 1). CT scanning confirms the presence of a complex abdominopelvic mass with ascites. The patient is scheduled for an exploratory laparotomy with ovarian cystectomy, but she is also counseled for a hysterectomy and staging procedure, to which she consents. The gynecologic oncologist is aware of the surgery and is available if required.

At laparotomy, a large pelvic abscess is encountered and, subsequently, 1700 mL of turbid fluid is drained from the abscess cavity. The abscess extends from the pubic symphysis in the midline to the umbilicus. The small intestine appears to be seeded with small implants, all < 5 mm in diameter. Both fallopian tubes are noted to be grossly dilated, rigid, and have a rougher appearance externally, with the right tube appearing more grossly abnormal. Multiple constrictions are seen along the course of the right tube, with obstruction at the transition area between the isthmus and the ampulla. The uterus, ovaries, and appendix appear to be grossly normal. No abnormalities of the liver, kidneys, or stomach are found. Multiple biopsies and cultures are taken and sent for analysis. Frozen-section analysis demonstrates "granulomatous reaction compatible with tuberculosis.”

Figure 3.

Figure 4.

Surgery is terminated at this point, with the midline incision being closed without drains following extensive irrigation. All cultures come back negative for bacteria and fungi, with the exception of the abscess, which grows acid-fast bacilli (AFB) on Lowenstein-Jensen medium in about 6 weeks. Testing for drug sensitivities shows no resistance to first-line tuberculosis agents. The biopsies reveal multiple caseating and noncaseating granulomas (Figures 2 and 3), with organisms compatible with Mycobacterium tuberculosis on AFB staining (Figure 4). A Gomori methenamine silver (GMS) stain examination is negative for fungal organisms. Postsurgery HIV tests are also negative; however, a PPD intradermal skin test (Mantoux test) is positive. The health department is notified.

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