1. Clinical Pathological Conference May 11, 2007

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

3. DEFENDING DIAGNOSES Ovarian Carcinoma (9): David Jacobs Krukenberg Tumor (1): Daniel Shen Pelvic Tuberculosis (3): Vanessa Starr Pancreatic adenocarcinoma (1): Jeremy Fenton Other Diagnoses: Meig’s syndrome Antiphospholipid syndrome Pseudomyxoma Peritonei

4. RADIOLOGY Dr. Michael Macari Associate Professor, Department of Radiology

5. Pelvic Ultrasound

14. FACULTY DISCUSSANT Dr. David Chong Associate Program Director Assistant Professor of Medicine, Pulmonary Disease

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

16. Right Ovary

19. Right Peritoneum

22. Right Iliac Lymph Node

25. FINAL DIAGNOSIS Pathologic Diagnosis: Non-caseating Granulomas Presumed Clinical Diagnosis: Tuberculosis of the Female Genital Tract

26. 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.

27. 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

28. 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

29. 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

30. 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

31. 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

32. Radiographic Features of Tuberculosis

33. 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

34. Thank you Medical Students Dr. Macari Dr. Chong Dr. Wei Dr. Grieco Dr. Blaser