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

Michel E. Rivlin, MD

Disclosures

January 26, 2016

Symptoms are usually present for weeks or months, and a history of close contact with an infected person, such as other family members, may be reported. Patients may have a personal history of pulmonary or extrapulmonary disorders, such as pleurisy, erythema nodosum, renal disease, and/or bone disease. A physical examination may be unremarkable except for mild weight loss. Ascites is present in as many as 97% of cases of tuberculous peritonitis. The abdomen can feel "doughy" and with irregular masses, which may be calcified and visible on abdominopelvic radiographs. A pelvic examination often shows findings similar to nontuberculous pelvic inflammatory disease; however, the bilateral masses are usually less tender and less uniform in consistency. The finding of bilateral inflammatory masses in a virginal female or of ascites in an adolescent, respectively, should raise suspicion for genital or peritoneal tuberculosis.[3,4,5]

In this patient, the presence of a pelvic mass with ascites and an elevated CA 125 led to the erroneous presumptive diagnosis of an ovarian malignancy; however, pelvic/peritoneal tuberculosis may be associated with elevated serum and peritoneal fluid CA 125 levels, and should always be kept in mind with such presentations. These levels can return to normal after successful drug therapy. Other conditions may cause granulomas with giant cells, including sarcoidosis, actinomycosis, and foreign-body reactions. Actinomyces, an anaerobic gram-positive bacterium, is only occasionally a cause of pelvic organ infection, usually in the presence of a long-standing intrauterine device. Sarcoidosis rarely involves pelvic organs, and this patient's ethnicity makes sarcoidosis a highly unlikely diagnosis (it is more common in black persons).[5]

The diagnosis is best established by successful culture of the organism and demonstrating the AFB with the Ziehl-Neelsen staining technique. Samples tested may be derived from peritoneal fluid, biopsies, pus from the abscess, sputum, urine, and/or menstrual fluid. Histopathologic diagnosis is usually based on premenstrual endometrial biopsy samples or biopsies obtained at laparoscopy or laparotomy (as in this case). Imaging studies are nonspecific and the findings include high-density ascites (which appear more radiopaque rather than radiolucent because the ascitic fluid is thick, usually as a result of blood or a proteinaceous exudate), adenopathy, adnexal masses, and omental and mesenteric thickening.

Hysterosalpingography may show characteristic tubal changes, including "pipe-stem" appearance and multiple fistulae; however, unlike in chronic pelvic inflammatory disease, the fimbriae are uninvolved. Further evaluation should include HIV status, chest radiography, and renal tract assessment (because 10% of patients with genital lesions have renal tuberculosis and vice versa). Positive cultures should be tested for drug resistance against all first-line agents.[3] Nucleic acid amplification tests (eg, polymerase chain reaction) have been approved in the United States for the diagnosis of tuberculosis in patients with positive sputum smears with high positive and negative predictive value, but in sputum-negative patients, the positive predictive value is only about 50%. Ultimately the diagnosis of tuberculosis involves a synthesis of clinical and laboratory findings.[6]

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