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Hematol Oncol Stem Cell Ther 1(1) January 2008 hemoncstem.edmgr.com66

To the Editor: Abdominal tuberssculosis continues to be a significant health problem in the developing world. Recently there has been an increase in the number of cases in those parts of world where it was rare due to increasing travel and migration and also due to a risssing number of HIV cases who are predisposed to opportunistic infections.1 Several reports have highlighted the remarkable similarssity between this illness and ovarian carcinoma.2 We report a case with ascites, pleural effusion and abdomssinocervical lymphadenopathy and bilateral cystic ovarian lesions and elevated CAs125 which could have been treated as ovarian carcinoma and subjected to surgical resections and chemotherapy and their consessquences.

A 47syearsold multiparous pressmenopausal woman presented with progressive abdominal distension of 4 weeks duration without any history of altered bowl habits, fessver or any significant medical hissstory. Examination revealed two mobile 2.5scm rightssided cervical lymph nodes, right pleural effusssion and ascites. Complete blood counts, kidney and liver functions were normal. ESR was 45 mm and ascitic and pleural fluid analysis ressvealed exudative lymphocyte pressdominant ascitic fluid. Cytology was negative for any malignant cells as was ascetic and pleural fluid AFB staining. Ultrasonography revealed ascites, bilateral 2scm3 cystic lesions in the ovaries and a normal liver, spleen, and kidneys. CT scan of the chest revealed right pleural effusion

A patient with ascites, pleural effusion, abdomi--nocervical lymphade--nopathy, bilateral ovarian cystic lesions and elevated CA-125 mimicking ad--vanced ovarian carcinoma

(Figure 1) and a normal mediastissnum. CT scan of the abdomen ressvealed ascites, multple paraaortic, paracaval, paracelial lymph nodes of variable size and confirmed bisslateral ovarian cysts (Figures 2, 3). Upper and lower GIT endoscopies were normal as was barium followsthrough. The possibility of ovarian carcinoma, lymphoma and tubercusslosis were considered. A Mantoux test was negative. CAs125 levels of 531 Mu/L (0s35 normal) increased the suspicion for ovarian carcinoma. However, excisional biopsy of the cervical lymph nodes revealed casessous lymphadenitis (Figure 4). The patient was started on a foursdrug regimen of antitubercular drugs, and within 4 weeks, ascites and pleural effusion disappeared. The patient was followed regularly and after 4 months of therapy a CT scan of the chest and abdomen were repeated, and revealed no pleural effusion, no ascites, resolved abdominal lymphssadenitis and persistent samessized ovarian cystic lesions (Figures 5, 6). CAs125 was repeated and had desscreased to 36.1 Mu/L. At that point the patient was doing well and was asymptomatic.

Tuberculosis continues to be an endemic disease in the developing countries.1 The risk factors for the development of tuberculosis include immigration, low income populasstions, immunosuppression, HIV, and living in close contact with passtients suffering from tuberculosis.1,2 Disseminated tuberculosis accounts for 1% to 3% of cases that suffer from tuberculosis.3 Peritoneal tuberculosssis has symptoms in common with advanced ovarian carcinoma. Pelvic pain and mass, ascites, and elevated serum CAs125 are wellsknown markers for ovarian cancer and for peritoneal tuberculosis. There are several case reports that point out the uncertainty in the preoperative differential diagnosis of peritoneal

Figure1.right pleural effusion before treatment.

Figure2.parabaortic lymph nodes before treatment.

Figure3.ascites.

tuberculosis and advanced ovarian cancer.1s15

Our patient presented with ascisstes, pleural effusion and abdominal lymph adenopathy. The difficult problem was to go for laparotomy, especially in the presence of bilaterssal cystic ovarian lesions and elevated CAs125. Elevation of CAs125 in peritoneal tuberculosis has been reported and misinterpreted with disseminated ovarian cancer with laprotomies and extensive surgisscal resections.16s20 The presence of

letters

Hematol Oncol Stem Cell Ther 1(1) January 2008 hemoncstem.edmgr.com 67

Abdul Majid Wani, Amer n. Khouja, Mugeena Akhtar

correspondence and reprint requests: abdul majid Wani mdconsultant of medicinehera General hospitalholy makkah, Saudi arabia 10513t: +96625220930, +966501693015f: +96625222830 dr_wani_majid@yahoo.com.in

We acknowledge Dr. Waleed Mohd Hussain (MD), Program Director,

1.mahdavi a malviya VK, Hirschman Br.peritoneal tuberculosis disguised as ovarian cancer; an emerging clinical challenge.Gynecol Oncol 2002; 84; 167b70.2. panoskaltsis Ta, moore Da, Haritopoulos Da, mclndoe aG. Tuberculosis peritonitis part of the differential diagnosis in ovarian cancer. am J Obbbstet GyneCOl 2000; 182; 740b23. F.m.Sanai and K i Bzeizi.systematic review; tuberculous peritonitisb presenting features, dibbagnostic strategies and treatment. aliment pharbbmocol Ther 2005; 22; 685b7004.lantheaume S,Soler S, issartel B et al.peritoneal tuberculosis simulating advanced ovarian carbbcinoma: a case report.Gynecol Obestet Fertil 2003;31;624b6.5.Groutz a, Carmon e, Gat a. peritoneal tuberculobbsis versus ovarian cancer; a diagnostic dielemma.Obestet Gynecol 1998; 91(pt2); 8686. Bilgin T, Kabay a, Dolar e, Develioglu OH.peritoneal tuberculosis with pelvic abdominal

Figure5.resolution of ascites after treatment.

Figure6.resolved lymph adenopathy.

Figure4.Caseous lymphadenitis.

Hera General Hospital, in encourag--ing us to write and pursue research.

REfEREnCES

mass,ascites and elevated Ca125 mimicking adbbvanced ovarian carcinoma; a series of 10 cases.int Gynecol Cancer 2001;11;290b4.7.penna l, manyonda i, amias a.intrababdominal military tuberculosis presenting as disseminated ovarian carcinoma with ascites and raisedCa125. BJOG1993; 100; 1051b3.8.Simsek H, Savas mC, Kadayifci a, Tstar G, am j Gastroenterology 1997; 92; 1174b6.9.Straughn Jm, robertson mW, partridge ee,. a patient presenting with a pelvic mass, elevated Ca125, and fever. Gynecol Oncol 2000; 77; 471b2.10.imai, itoh T, niwa K, Tamaya T.elevated Ca125 levels in a patient with tuberculous peritonitis.arcg Gynecol Obestet 1991; 248; 157b9. 11.Thakur V, mukerjee u, Kumar K.elevated serum cancer antigen 125 levels in advanced abdominal tuberculosis. med Oncol 2001; 18:289b91.12.Geisler Jp, Crook De, Geisler He et al.The great imitator: miliary peritoneal tuberculosis mimicking stage iii ovarian carcinoma. South med J 2001; 94:1212b4.13.piura B, rabinovich a, leron e, yanaibinbar i, mazor m. peritoneal tuberculosis mimickingovarbbian carcinoma with ascites and elevated serum Ca 125.case report and review of literature. eur J Gynecol Oncol 2002; 23:120b2.14.protopapas a, milings S,Diakomanolis e et

a cervical lymph node and its excisssional biopsy prevented our patient from laparotomy and/or surgery and chemotherapy. The positive predictive value of the serum CAs125 to detect malignancy has been estimated at 60% generally, rising to 98% in postmenopausal women.6,8

The sensitivity and specificity of the CAs125 declines in the pressmenopausal age groups, presumssably because of the high incidence of benign conditions that can cause elevation of this marker.6 For this reason, in young patients with elssevated serum CAs125 levels, tuberssculosis should be considered in the differential diagnosis, especially in areas where tuberculosis is endemssic.2,8 Furthermore, CAs125 levels seem to serve as a potential followsup marker of the disease activity in benign disease like tuberculosis.21s23 This was seen in our case also and the fall in CAs125 paralleled clinical and radiological improvement.

In conclusion, tuberculosis must always be considered in premenosspausal women with low socioecossnomic status, who are living in enssdemic areas of tuberculosis and with presenting signs of ovarian cancer like a pelvic mass, ascites, serum CA125 elevation, pleural effusion and abdominal lymphadenopathy. CA125 can be useful marker in the follow up of a benign disease like tuberculosis.