|Year : 2005 | Volume
| Issue : 4 | Page : 125-126
An unusual case of large tubercular tubo-ovarian masses
Umesh N Jindal
Consultant Gynaecologist and Director, Jindal IVF & Sant Memorial Nursing Home, 3050, Sector 20-D, Chandigarh., India
Umesh N Jindal
Consultant Gynaecologist and Director, Jindal IVF & Sant Memorial Nursing Home, 3050, Sector 20-D, Chandigarh.
| Abstract|| |
We report a rare and unusual presentation of tubo-ovarian tuberculosis managed conservatively with transvaginal ultrasound guided aspiration.
|How to cite this article:|
Jindal UN. An unusual case of large tubercular tubo-ovarian masses. Lung India 2005;22:125-6
| Introduction|| |
Incidence of extra pulmonary tuberculosis (ETB) has increased worldwide.  Female genital TB (GTB) is one of the common types of ETB seen. Most common presentation of GTB is infertility.  However, GTB can affect females of any age and mimic any gynaecological disease. GTB presenting as large pelvic masses are often confused with malignant ovarian tumours and present both as a diagnostic and therapeutic dilemma.  We report here a case of GTB with very large pelvic masses which was diagnosed and managed conservatively by ultrasound guided transvaginal aspiration and ATT.
| Case Report|| |
Mrs K.M., 47 year old, educated housewife belonging to a good socio-economic status presented with chief complaints of pain in the lower abdomen which was mild to moderate in intensity and accompanied by high fever (101-102 o F). Except for some prolongation of interval between the cycles, her menstrual history was unremarkable. No other contributory family or past history was available.
She was married for 20 years and her first child was born after 5 years of marriage. Since then, she had developed secondary infertility. She underwent some investigations and treatment but no records were available. She was aware of the presence of big pelvic masses detected on ultrasound examination on multiple occasions for the last 3-4 years. She had been avoiding surgery which was advised by many doctors previously. A possibility of endometriosis or malignancy was considered.
On examination, she was comfortable and not sick looking. She had mild fever but the general physical examination was normal. Abdominal examination revealed a mildly tender suprapubic mass extending upto midway between pubic symphysis and umbilicus. There was no ascites. Same mass could be felt on pelvic examination which was firm in consistency, slightly tender and was filling the entire pelvis. These masses were felt on both sides of a normal sized uterus.
Ultrasound examination confirmed the presence of large adnexal masses on both sides [Figure 1], which was thick walled with thick sepatations and multiple cystic spaces of variable echogenicity. She had mild polymorphonuclear leucocytosis. Her blood biochemistry was normal. She was started on broad spectrum antibiotics and a diagnostic-cum-therapeutic transvaginal ultrasound guided aspiration was done under general anaesthesia. All the loculi were drained and nearly 600 ml of thick, foul-smelling pus was drained. Both the masses could be drained only partly because the pus was very thick. Culture for pyogenic bacteria grew Pseudomonas aerogenosa which was sensitive to all routine antibiotics. Zeihl Neelsen stain was negative for AFB. She was diagnosed as a case of long standing tubo-ovarian masses with superimposed bacterial infection. She was started on standard 4 drug regimen of Rifampicin (600 mg), INH (300 mg), Ethambutol (800 mg) and pyrazinamide (1500 mg) daily after the aspiration with a presumptive diagnosis of tuberculosis on clinical grounds. In addition, Amikacin was also given to cover Pseudomonas infection. The positive polymerase chain reaction (PCR) for mycobacteria in the pus sample obtained after aspiration confirmed the diagnosis of tuberculosis.
The patient took almost 2 months to become completely afebrile and by that time right-sided mass had resolved completely while left sided mass had also decreased significantly. She was continued on ATT and after 6 months both side masses have completely resolved. She was advised to continue 2 drugs (Rifampicin 600 mg and INH 300 mg) for another 3 months because of slow regression of the masses.
| Discussion|| |
Fallopian tube More Detailss are the most common sites of involvement in GTB.  This patient presented with many interesting features. Firstly, such large tubo-ovarian masses of TB etiology are very rare. Perhaps the super added infection which was a community acquired infection, increased the volume of pre-existing masses. Secondly, the only ultrasound feature, which could distinguish these masses from endometriosis or malignant ovarian tumour, was the presence of thick walled septations  . History of long standing infertility, presence of the masses for a few years, and history of fever indicated an inflammatory etiology. TB being endemic in India and a common cause of infertility, a clinical diagnosis of tubercular tubo-ovarian masses was made.
Detection of MTB by PCR is a quick and sensitive method. Low detection rate by traditional culture methods in genital tissues and fluids have been well documented  . PCR has been successfully used to diagnose TB of the peritoneum, meninges and many other organs with paucibacillary involvement, whereas histology and/or AFB smear and culture have a poor sensitivity. ,
Lastly, it was interesting to see these large masses completely resolving with antitubercular chemotherapy. Moreover, a major surgery in a highly inflamed abdomen due to combined TB and pyogenic infection, with all its accompanying hazards could be avoided by ultrasound guided closed drainage.
To conclude, this case demonstrates a rare presentation of a common disease, which was diagnosed with the help of ultrasound and PCR for MTB. Conservative management in the form of closed drainage with transvaginal ultrasound guided aspiration and a standard short course ATT proved as a highly successful treatment.
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