Sonographic Features of Female Pelvic Tuberculous Peritonitis

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1 Image Presentation Sonographic Features of Female Pelvic Tuberculous Peritonitis Theera Tongsong, MD, Kornkanok Sukpan, MD, Chanane Wanapirak, MD, Supatra Sirichotiyakul, MD, Fuanglada Tongprasert, MD Objective. The purpose of this study was to evaluate the sonographic features of tuberculous peritonitis in an attempt to facilitate the recognition of this disorder preoperatively. Methods. The sonographic findings of 16 patients who had tuberculous peritonitis were reviewed. Results. The sonographic findings showed that 14 of the 16 patients had ascites; 10 of these had fine, complete and incomplete mobile septations. Of these 10 patients, 4 had ascites with a latticelike appearance, and 2 had ascites with a parallel violin string appearance, which to our knowledge has not been described previously; 3 had particulate ascites. Peritoneal and omental thickening or nodules were identified in 9 patients. Two patients showed bilateral complex adnexal masses with multiloculated fluid with a thick wall-like tubo-ovarian abscess. Conclusions. Tuberculous peritonitis seems to have characteristic sonographic features, especially the findings of peritoneal and omental thickening and ascites with fine, mobile septations. These sonographic findings may provide valuable information to help with further investigations and may prevent unnecessary laparotomies. Key words: sonography; tuberculosis; tuberculous peritonitis. bbreviations C 125, cancer antigen 125; T, tuberculosis Received July 25, 2006, from the Departments of Obstetrics and Gynecology (T.T., C.W., S.S., F.T.) and Pathology (K.S.), Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand. Revision requested ugust 10, Revised manuscript accepted for publication ugust 23, ddress correspondence to Theera Tongsong, MD, Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand. ttongson@mail.med.cmu.ac.th Tuberculosis (T) causes approximately 3 million deaths per year worldwide, and its incidence is increasing in developed as well as in developing countries, particularly in patients with immunodeficiency associated with human immunodeficiency virus infection. Tuberculous peritonitis is the third leading cause of ascites after cirrhosis and malignancy; however, establishing a diagnosis of tuberculous pelvic peritonitis is frequently difficult, and in most cases, the diagnoses are made postoperatively. It can mimic many conditions, including inflammatory bowel disease, malignancy, and other infectious diseases 1 7 ; therefore, diagnosis is often delayed. This may result not only in death but also in unnecessary surgery. Preliminary reports have suggested, however, that a careful sonographic examination may lead to an exact diagnosis before surgery lthough several studies on tuberculous peritonitis have been reported, only a few studies 8 11 have focused on the sonographic features of this disorder, 2007 by the merican Institute of Ultrasound in Medicine J Ultrasound Med 2007; 26: /07/$3.50

2 Tuberculous Peritonitis and the number of cumulative cases existing in the literature is still minimal. The aim of this series was to illustrate these features on the basis of our experience with patients subsequently proved to have pelvic T in an attempt to facilitate the detection of this disorder preoperatively. Materials and Methods From June 1995 to May 2006, the full medical records of patients with the diagnosis of female pelvic peritonitis were collected and reviewed. The diagnosis of T was based on histopathologic or microbiologic evidence in the tissue obtained either via laparotomy or peritoneoscopy or on positive cultures for acid-fast bacilli in ascitic fluid. This series included only those patients who had a preoperative sonographic examination and for whom sonographic multiformat film images or video clips were available. The patients had an initial transabdominal scan with a full bladder followed by a transvaginal examination after the bladder was emptied. Sonographic examinations were performed by the authors with an SSD or a Prosound 5000 system (loka Co, Ltd, Tokyo, Japan) or a Voluson 730 system (GE Healthcare, Milwaukee, WI) with a 3.75-MHz mechanical transabdominal convex transducer or 5- to 7.5-MHz transvaginal probes. Results total of 21 patients with pelvic T were recruited into the study; however, 5 patients had no available sonographic multiformat images or video clips for review. The sonographic findings showed some characteristic features (Table 1), especially those of peritoneal and omental thickening and ascites with fine, mobile septations. Of Table 1. Sonographic Findings of the Patients Finding No. of Cases scites 13 Incomplete mobile septations 10 scites with a latticelike appearance 4 Particulate ascites 3 Parallel violin strings 2 Peritoneal thickening or omental thickening/nodules 9 Tubo-ovarian abscess appearance 2 Complex solid mass 1 the 16 patients, 13 had wet-type T, with predominant ascites; 3 had dry-type (adhesive) T, with an appearance mimicking a tubo-ovarian complex or an abscess. The sonographic features of tuberculous peritonitis with female genital tract T can be summarized as follows: relatively specific ascites in most cases (13 patients), in which there were either incomplete or mobile septations (10 patients) (Figure 1); a thickening band or nodular masses in the ascites (peritoneal thickening) or omental thickening (9 patients) (Figure 2); and an appearance simulating a tuboovarian abscess or complex (Figure 3), in which patients had an initial diagnosis and treatment of a tubo-ovarian abscess but with no response (3 patients). Interestingly, of the 10 patients with ascites, 4 had typical ascites with a latticelike appearance (Figure 4), 3 had echogenic particulate ascites (Figure 5), and 2 had ascites with a typical parallel violin string appearance (Figure 6), which to our knowledge has not been described previously. In most cases, the diagnoses were based on the histopathologic examination of tissue obtained via laparotomy (7 patients, including 3 for failed medical treatment of pelvic inflammatory disease, 3 with assumed mucinous ovarian tumors, and 1 with an ovarian tumor) or peritoneoscopy (6 patients); cytologic examinations diagnosed T for the others (3 patients). Of the 10 patients, 4 had positive lung lesions of T, and 3 had T of the endometrium. Discussion diagnosis of tuberculous peritonitis is always difficult, especially in the absence of abnormal lung lesions, and it is often established after unnecessary surgery for ovarian cancer as the provisional diagnosis. This is because both entities can have similar clinical manifestations, elevated cancer antigen 125 (C 125) levels, and an overlapping sonographic appearance. Without careful sonographic examination, tuberculous peritonitis can easily be mistaken for an ovarian carcinoma. 6 Several cases in this series were initially diagnosed as ovarian malignancies because of sonographic results that were supported by elevated C 125 levels. It should be emphasized, therefore, that raised C 125 levels and sonographic results can be misleading, and 78 J Ultrasound Med 2007; 26:77 82

Tongsong et al Figure 1., Cross-sectional scan at the lower abdomen shows relatively clear ascites with incomplete mobile septations (arrowheads).

frozen-section analysis is important for a definitive diagnosis to avoid unnecessary surgery.

film results that are abnormal or in patients with human immunodeficiency virus infection.

This series shows that only 4 (25%) of the 16 patients had chest film results that were abnormal, unlike the findings reported by Wang et al, 12 who showed that 74% of 35 patients with tuberculous

3 Tongsong et al Figure 1., Cross-sectional scan at the lower abdomen shows relatively clear ascites with incomplete mobile septations (arrowheads)., Cross-sectional scan at the lower abdomen of a different patient shows somewhat turbid ascites with relatively thick and incomplete mobile septations (arrowheads). frozen-section analysis is important for a definitive diagnosis to avoid unnecessary surgery. Tuberculous peritonitis should be part of the differential diagnosis in ovarian cancer, especially in cases that are not typical for malignancy or with other evidence that suggests T, such as chest film results that are abnormal or in patients with human immunodeficiency virus infection. Notably, the absence of lung lesions suggestive of T should not exclude the possibility of tuberculous peritonitis. This series shows that only 4 (25%) of the 16 patients had chest film results that were abnormal, unlike the findings reported by Wang et al, 12 who showed that 74% of 35 patients with tuberculous peritonitis showed abnormalities on chest radiographs. On the basis of this study and on previous reports, 8,10 although no features alone or in combination are pathognomonic for T, septated ascites, particularly the type accompanied by dilatation, and constriction of fallopian tubes that are filled with material having low echogenicity, a thickened peritoneum, and a thickened or nodular omentum are highly suggestive of tuberculous peritonitis with female genital tract T. Figure 2., Parasagittal scan at right adnexa shows loculated fluid with several septations with echogenic nodular masses (arrowheads) representing peritoneal thickening or omental thickening., Transvaginal scan of the left adnexa shows a poorly defined complex mass (arrowheads) representing peritoneal or omental thickening. J Ultrasound Med 2007; 26:

band or adhesion (arrowheads), simulating a tubo-ovarian abscess or complex.

The pelvic wall and posterior uterine wall form as a wall of these fluid collections, simulating a pelvic abscess.

Other modalities such as peritoneoscopic examination may be another option, and polymerase chain reaction examination of ascitic fluid obtained by sonographically guided fine-needle aspiration to

4 Tuberculous Peritonitis Figure 3., Transabdominal scan of the right adnexa shows a complex mass surrounded by pelvic structures containing several round areas of loculated fluid (F) that vary in size and are separated by a thickened band or adhesion (arrowheads), simulating a tubo-ovarian abscess or complex., Transabdominal cross-sectional scan shows the 2 loculated fluid areas posterior to the uterus separated by a thickened adhesion band (arrowhead). The pelvic wall and posterior uterine wall form as a wall of these fluid collections, simulating a pelvic abscess. wareness of the sonographic changes associated with T infection may improve diagnostic accuracy and avoid clinical mismanagement and surgical explorations for wet-type T. Other modalities such as peritoneoscopic examination may be another option, and polymerase chain reaction examination of ascitic fluid obtained by sonographically guided fine-needle aspiration to establish the diagnosis should at least be attempted before surgical intervention. 9 The finding of peritoneal and omental thickening, especially when accompanied by ascites with fine, mobile septations, strongly suggests tuberculous peritonitis, as shown by Demirkazik et al, 10 who used a combination of computed tomographic and sonographic examinations. On the basis of our series and the findings of Yapar et al, 8 the sonographic features of pelvic T may be categorized as wet type (ascites) or dry type (adhesive) as follows. The wet type, found in 12 (75%) of 16 patients, is characterized by incompletely septated ascites, particulate ascites, Figure 4., Transabdominal cross-sectional scan shows an extensive lattice network of fibrin bands (arrowheads) in ascites., Transabdominal cross-sectional scan of the lower abdomen shows ascites with a latticelike appearance formed by organized fibrin bands (arrowheads). 80 J Ultrasound Med 2007; 26:77 82

Tongsong et al Figure 5., Transvaginal scan shows a large pocket of echogenic dense and fine particulate ascites in the cul-de-sac ( indicates bladder).

loculated fluid (although clear ascites can also be commonly associated with tuberculous peritonitis 13 ), a thickened peritoneum or omentum, and an adnexal mass, mimicking ovarian cancer; the dry

This study suggests that the recognition of these sonographic features may be more relevant and practical than ascites fluid studies, chest radiographs, tuberculin skin tests, and sputum cultures.

dditionally, tuberculous peritonitis should be considered in cases of tubo-ovarian abscesses for which medical treatment fails or in cases of ovarian cancer with some unusual sonographic findings

5 Tongsong et al Figure 5., Transvaginal scan shows a large pocket of echogenic dense and fine particulate ascites in the cul-de-sac ( indicates bladder)., Transabdominal cross-sectional scan at the lower abdomen shows coarse particulate ascites with numerous echogenic dots suspended in the ascites. loculated fluid (although clear ascites can also be commonly associated with tuberculous peritonitis 13 ), a thickened peritoneum or omentum, and an adnexal mass, mimicking ovarian cancer; the dry type, found in a small number of cases, is characterized primarily by adnexal masses, adhesions, and loculated fluid, mimicking tuboovarian abscesses or complexes. This study suggests that the recognition of these sonographic features may be more relevant and practical than ascites fluid studies, chest radiographs, tuberculin skin tests, and sputum cultures. Interestingly, the parallel violin string appearance visualized in 2 patients, although occurring rarely, may possibly be typical of tuberculous peritonitis. dditionally, tuberculous peritonitis should be considered in cases of tubo-ovarian abscesses for which medical treatment fails or in cases of ovarian cancer with some unusual sonographic findings such as ascites with mobile septations or a latticelike pattern, a parallel violin string appearance, or particulate ascites. s in other studies, several cases in this series were initially diagnosed as ovarian cancer because of a pelvic mass with ascites. This study Figure 6., Transabdominal midsagittal scan of the lower abdomen shows a typical parallel violin string appearance (arrowheads)., Transabdominal cross-sectional scan at the level above the uterus shows the parallel violin string appearance (arrowheads) in ascites. J Ultrasound Med 2007; 26:

6 Tuberculous Peritonitis suggests that some unusual sonographic findings, especially an area of ascites with incomplete mobile septations or particulate ascites, should be considered indicative of tuberculous peritonitis. The limitations of this study include its retrospective nature and the relatively small number of patients, which resulted in an inability to assess the sensitivity and accuracy of sonographic examinations in the diagnosis of pelvic T. Other limitations included no male patients, no case cohorts with complex ascites who did not have T, and the fact that all patients were seen at only 1 hospital in Thailand. In conclusion, tuberculous peritonitis tends to have characteristic sonographic features that include (1) ascites with fine, mobile septations, (2) peritoneal and omental thickening, and (3) a poorly defined mass. The sonographic findings may provide valuable information to help with further investigations and may prevent unnecessary laparotomies. 9. Uzunkoy, Harma M, Harma M. Diagnosis of abdominal tuberculosis: experience from 11 cases and review of the literature. World J Gastroenterol 2004; 10: Demirkazik F, khan O, Ozmen MN, kata D. US and CT findings in the diagnosis of tuberculous peritonitis. cta Radiol 1996; 37: khan O, Demirkazik F, Demirkazik, et al. Tuberculous peritonitis: ultrasonic diagnosis. J Clin Ultrasound 1990; 18: Wang HK, Hsueh PR, Hung CC, Chang SC, Luh KT, Hsieh WC. Tuberculous peritonitis: analysis of 35 cases. J Microbiol Immunol Infect 1998; 31: Malik, Saxena NC. Ultrasound in abdominal tuberculosis. bdom Imaging 2003; 28: References 1. Tapisiz OL, Reyhan H, Cavkaytar S, ydogdu T. Pelvic tuberculosis mimicking ovarian carcinoma. Int J Gynaecol Obstet 2005; 90: Protopapas, Milingos S, Diakomanolis E, et al. Miliary tuberculous peritonitis mimicking advanced ovarian cancer. Gynecol Obstet Invest 2003; 56: Odejinmi F, nnan HG, Hussein SY. Tuberculosis, the great mimic again? report of two cases of pelvic tuberculosis initially suspected to be advanced ovarian carcinoma. J Obstet Gynaecol 2000; 20: Koc S, eydilli G, Tulunay G, et al. Peritoneal tuberculosis mimicking advanced ovarian cancer: a retrospective review of 22 cases. Gynecol Oncol 2006; 103: Ilhan H, Durmusoglu F. Case report of a pelvic-peritoneal tuberculosis presenting as an adnexal mass and mimicking ovarian cancer, and a review of the literature. Infect Dis Obstet Gynecol 2004; 12: ilgin T, Karabay, Dolar E, Develioglu OH. Peritoneal tuberculosis with pelvic abdominal mass, ascites and elevated C 125 mimicking advanced ovarian carcinoma: a series of 10 cases. Int J Gynecol Cancer 2001; 11: Jadvar H, Mindelzun RE, Olcott EW, Levitt D. Still the great mimicker: abdominal tuberculosis. JR m J Roentgenol 1997; 168: Yapar EG, Ekici E, Karasahin E, Gokmen O. Sonographic features of tuberculous peritonitis with female genital tract tuberculosis. Ultrasound Obstet Gynecol 1995; 6: J Ultrasound Med 2007; 26:77 82

American Journal of Oral Medicine and Radiology

American Journal of Oral Medicine and Radiology e - ISSN - XXXX-XXXX ISSN - 2394-7721 Journal homepage: www.mcmed.us/journal/ajomr ULTRASONOGRAPHIC EVALUATION OF ADNEXAL MASSES Nageswar Rao* Professor,