Tuberculous tubo-ovarian abscess and peritonitis

Case contributed by Dr Michael P Hartung

Presentation

Several month history of pelvic discomfort.

Patient Data

Age: 25 years
Gender: Female

Large bilateral irregular, lobulated, enhancing adnexal masses, The left has a tubular component which is thickened, and hyperenhancing, coursing along the medial periphery of what is likely the ovarian component. The right has a larger central fluid component. 

Extensive peritoneal thickening and enhancement with small to medium amount of ascites. Stranding throughout the upper abdominal omentum. Serosal thickening/hyperenhancement of the small bowel diffusely.

Case Discussion

Ascites aspirate confirmed tuberculosis (TB) resulting in tubo-ovarian abscess (TOA). 

The extent of peritoneal disease with bilateral ovarian masses is certainly concerning for carcinomatosis at first glance.

However, there are several features that support an infectious/inflammatory cause: smooth peritoneal and serosal thickening and hyperenhancement (indicating peritonitis, and commonly described as "wet" peritoneal TB2), left adnexal hydro/pyosalpinx, and the lack of peritoneal nodularity/implants.

TB TOA's have the following characteristics:

  • caused by hematogenous, lymphatic, or peritoneal spread
  • mimic ovarian cancer by presenting with vague symptoms and elevated CA-125

Uncommon causes of TOA abscess that can present in this way including actinomyces (particularly in the setting of longstanding IUD) and TB. These are often mistaken for cancer, and are important alternate diagnoses to keep in mind. In this case, fluid aspiration and culture was recommended as infectious/inflammatory causes were favored.

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