Clinical Pathological Conference

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Clinical PathologicalConference

• May 11, 2007

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CHIEF COMPLAINT

• 51 year old female with abdominal bloating,
  twenty pound weight loss, and fatigue
• for 2 months.

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DEFENDING DIAGNOSES

• Ovarian Carcinoma (9) David Jacobs
• Krukenberg Tumor (1) Daniel Shen
• Pelvic Tuberculosis (3) Vanessa Starr
• Pancreatic adenocarcinoma (1) Jeremy Fenton
• Other Diagnoses
• Meigs syndrome
• Antiphospholipid syndrome
• Pseudomyxoma Peritonei

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RADIOLOGY

• Dr. Michael Macari
• Associate Professor,
• Department of Radiology

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Pelvic Ultrasound
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Pelvic Ultrasound
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FACULTY DISCUSSANT

• Dr. David Chong
• Associate Program Director
• Assistant Professor of Medicine,
• Pulmonary Disease

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PATHOLOGY

• Dr. Jian-jun Wei
• Assistant Professor,
• Department of Pathology

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Right Ovary
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Right Ovary
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Right Ovary
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Right Peritoneum
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Right Peritoneum
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Right Peritoneum
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Right Iliac Lymph Node
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Right Iliac Lymph Node
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Right Iliac Lymph Node
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FINAL DIAGNOSIS

• Pathologic Diagnosis Non-caseating Granulomas
• Presumed Clinical Diagnosis
• Tuberculosis of the Female Genital Tract

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Hospital Course and Follow-up

• The patient had a GI and GYN workup for
  malignancy.
• Her EGD showed
• Normal esophagus. Atrophic mucosa in antrum.
  Normal dudodenum.
• Negative Helicobacter pylori.
• Pathology chronic mildly active gastritis with
  extensive metaplasia.

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Hospital course and Follow-up

• The patient had an exploratory laparotomy
• Evidence of miliary disease
• Bilateral oopherectomy and hysterectomy
• Pathology Non-caseating granulomas. (AFB -)
• Tuberculosis versus Sarcoidosis
• 6 month course of IRPE 6 given for presumed
  tuberculosis of the female genital tract

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Epidemiology of Tuberculosis of the Genital Tract

• Common in underdeveloped nations
• Most affected woman are in the reproductive
  age-group
• In Guyana,
• 900 new cases of active tb per year
• estimated annual rate of infection is 3.2
• estimated 14 of the population is infected

World TB report 2005
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Pathogenesis of Miliary Tuberculosis
Bacilli in the air (droplet nuclei) inhaled
Replication in dependant lobe primary focus
Early lymphohematogenous spread
Latent Foci
TB lymphadentis, Miliary Tuberculosis
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Clinical Presentation and laboratory data of
Tuberculosis of the Genital Tract

• Abdominal pain
• Pelvic pain
• Ascites
• Diarrhea
• Infertility
• Weight loss

• Amenorrhea or irregular menses
• Fever
• Anemia
• Elevated CA-125

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Making the Diagnosis of Tuberculosis of the
Genital Tract

• Laparoscopically directed biopsy
• Premenstrual endometrial tissue biopsy
• Histologic and PCR tests of peritoneal fluid,
  menstrual blood culture
• Exploratory laparotomy

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Radiographic Features of Tuberculosis
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Treatment of Tuberculosis of the Genital Tract

• Similar to treatment for TB at extrapulmonary
  sites.
• A 6-mo regimen
• 2 months of isoniazid, rifampin, and pyrazinamide
• 4 months of isoniazid and rifampin
• Ethambutol should be used until the results of
  drug susceptibility studies are available, unless
  there is little possibility of drug resistance

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Thank you

• Medical Students
• Dr. Macari
• Dr. Chong
• Dr. Wei
• Dr. Grieco
• Dr. Blaser