Empirical Management of Radiologically Suspected Pelvic Tuberculosis in a 13-Year-Old Girl in the Absence of Microbiological Evidence- A Case Report View PDF

^*Sathiya Priya
Department Of Obstetrics And Gynecology, Jawaharlal Institute Of Postgraduate Medical Education And Research, Puducherry, India

^*Corresponding Author:

Sathiya Priya
Department Of Obstetrics And Gynecology, Jawaharlal Institute Of Postgraduate Medical Education And Research, Puducherry, India
Email:sathiyapriyasubburaj@gmail.com

Published on: 2020-12-21

Abstract

Tuberculosis is a major health problem affecting approximately 1 million children and young adolescents worldwide every year, 2 lakh deaths related to the disease. Adolescents are at a sixfold increased risk of acquiring tuberculosis due to a wider range of social contacts, risky substance use, mental health issues, infections with Human Immunodeficiency Virus and infection persists because of difficulties in completing treatment due to higher rates of loss to follow up. We are reporting a 13-year-old unmarried girl who presented with bilateral adnexal masses which resolved with empirical Anti-Tubercular therapy.

Keywords

Adnexal Disease; Antitubercular Drug; Adolescents

Introduction

Tuberculosis (TB) is one of the major global health problems. Every year 10 million new cases are diagnosed and 1.33 million death are reported, of which 85% are from developing countries [1]. Tuberculosis can be pulmonary and extrapulmonary involving lymph nodes, bone, kidney, genitourinary system, etc. Genitourinary TB constitutes 27.1% whereas genital tuberculosis constitutes only 9% percent due to vague symptoms, underreporting of cases, and lack of reliable diagnostic techniques [2,3]. Although genitourinary tuberculosis is common, reports of isolated ovarian tuberculosis are rare. Isolated ovarian tuberculosis mimics ovarian malignancy leading to a dilemma in diagnosis. We present a young girl who presented with bilateral adnexal mass to a tertiary hospital in South India.

Case

A 13-year-old unmarried girl presented with complaints of intermittent, dull aching, lower abdominal pain, fever, and vomiting for 3 weeks duration for which she was treated at a local hospital with parenteral antibiotics for 14 days. She was referred to our tertiary center as it did not resolve. She had attained menarche one year ago and her cycles were infrequent once in 3 months with a moderate flow for 5-6 days and no dysmenorrhea. Her last menstrual period was 20 days back. Preceding these symptoms, she had chickenpox for which she had received treatment. On examination, vitals were stable and a sixteen weeks size non-tender cystic mass was palpable in the hypogastric region. Ultrasound revealed bilateral complex adnexal masses, 8×8 cm each invading the rectouterine pouch suggestive of inflammatory etiology. There was no free fluid and no evidence of metastasis. CXR and Mantoux were negative. Although the CT scan concurred with ultrasound findings, in addition there was mesenteric lymphadenitis (Figure 1). ESR was 10 mm /hr. CA 125 was 54 U/ml and other tumor markers were negative. Mycobacterium culture of sputum and menstrual blood was negative. As there was no response to antibiotics and the presence of mesenteric lymphadenitis, led to a suspicion of tuberculosis.

After consultation with a Pulmonary physician, presumptive extra-pulmonary tuberculosis clinically and radiologically diagnosed case and was started on daily antitubercular therapy with 2HRZE as intensive phase and 4HRE as a continuation phase as per the RNTCP guidelines based on body weight for 6 months. She was discharged after her symptom subsided and advised to continue ATT. Follow up scan after 3 months showed no adnexal mass with CA-125 in a normal range (Figure 2). She had been having regular menstrual cycles with no recurrence of symptoms.

Discussion

Female genitourinary tuberculosis is the second most common site of extrapulmonary tuberculosis next to lymph nodes. In India, the incidence of female genital tuberculosis (FGTB) varies in different areas and ranges between 1-19% [4,5]. The most common causative organism is Mycobacterium tuberculosis, and it is usually secondary to pulmonary tuberculosis. Although genital TB can occur in any age group, reproductive age group women are most commonly affected, with the increasing incidence among children and young adolescents [6]. The nearer the menarche the primary infection occurs they are more likely to be affected with pelvic tuberculosis. Pelvic tuberculosis usually presents with tubo-ovarian mass or hydrosalpinx while isolated ovarian tuberculosis is rare. Most women with this presentation are frequently presumed to have advanced-stage ovarian cancer; therefore, peritoneal and/or adnexal mass tissue acquisition for the pathological study is pertinent for confirmation. FGTB may be primary or secondary. Primary tuberculosis is seen in sexually active females and usually together with a uterine or vaginal tuberculosis. The secondary form which is more common is caused by lymphatic or hematogenous dissemination from primary pulmonary tuberculosis or reactivation of latent foci. The fallopian tube is the most common site of involvement in 90-100% of patients, whereas endometrium 50-80%, ovaries-20-30 %, cervix-5%, vulva, and vagina-1%. Genital TB is silent and insidious having a slow progressive benign course with lesion unhealed for years to become active again under stress and strain. Most patients are asymptomatic (11%), may present with infertility (40- 60%), pelvic or abdominal pain or mass (50%), menstrual disorders (25%), constitutional symptoms like fever, fatigue, weight loss, loss of appetite, and physical examination can be normal in up to 50% of cases [2]. Tuberculous peritonitis is seen in 50% of FGTB patients. Diagnosis of FGTB is difficult due to the paucibacillary nature of infection and difficulty in obtaining samples for culture or biopsy. The serological tests used to diagnose pulmonary tuberculosis are having low sensitivity and specificity for diagnosing FGTB hence WHO as well as the Government of India do not recommend its use [7]. CA-125, which is produced by the inflammation of the epithelial cells of the coelomic cavity secondary to peritoneal involvement is elevated in both epithelial ovarian malignancy and tuberculosis, but it is usually <200 IU/ml in tuberculosis, and normalization after antitubercular therapy, as evident in our case [8]. In the case of pelvic mass, tuberculosis is difficult to diagnose due to features that are indistinguishable from ovarian malignancy such as insidious onset, nonspecific findings such as infertility, irregular menstrual cycles, abdominal pain, ascites, and complex adnexal mass with wall thickening, pseudo solid areas, peritoneal thickening and omental thickening on USG and CT. Mantoux test, CXR, endometrial sampling in the premenstrual phase, cultures, PCR, DNA probe methods, and T-cell diagnostics are other tests to diagnose FGTB. Diagnostic laparoscopy is the gold standard to diagnose FGTB with biopsy being specific and definitive. Coming to our patient she is an adolescent girl who presented with constitutional symptoms and irregular menstrual cycles, which can be due to immature hypothalamic functioning or endometrial involvement. The presence of pelvic mass with mildly elevated ca-125 can be confused with ovarian cancer but can be ruled out with other features specific to tuberculosis like affecting people with younger age, constitutional symptoms with mesenteric lymphadenitis as evident in our case and resolution of symptoms following antitubercular therapy. The possibility of pelvic TB should be considered in the differential diagnosis of ovarian carcinoma, especially in young girls in developing countries because the management is entirely different for both the conditions. Knowledge of the clinical and radiologic presentations is paramount for early detection and diagnosis considering tuberculosis as one of the diagnostic workups in young girls with adnexal mass thus avoiding the need for an unnecessary laparotomy [9].

Conclusion

A high index of suspicion for tuberculosis is necessary for a young patient with bilateral complex adnexal masses in developing countries like India. A multidisciplinary team approach with gynecologists, radiologists, and pulmonary physicians is needed to provide optimal care.