Barbosa, L.

Cunha, Teresa Margarida

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Case 9341 It seemed a terrible pelvic tumor...Barbosa L, Cunha TM Hospital dos Covões  Genital (Female) Imaging Section: 2011, Sep. 12 Published: 65 year(s), femalePatient:Authors' InstitutionInstituto Português de Oncologia de Lisboa Francisco Gentil E.P.E. - PortugalClinical HistoryA 65-year-old woman, nurse, residing in Bissau, Guinea, came to the emergency departmentbecause she was having asthenia, weight loss and diffuse abdominal pain complaints for a month.Imaging FindingsA CT was performed, revealing an enlargement of the ovaries and uterus in the pelvic cavity withcentral hypodensity, compatible with lesions of the endometrium, which extended inferiorly to thecervix (2).The MRI confirmed an increased size of the uterine body, where an endometrial tumour was noted.This tumour showed cervical invasion, but did not extend to the outer half of the myometrium orparametrial nor the bladder or rectum (3).A bilateral adnexal lesion was also visualised, which showed a tubular shape with internal fluid,suggesting bilateral lesion of the fallopian tubes, which was interpreted as bilateral tubal metastasesand possibly involvement of the ovaries.Following tuberculostatic treatment MRI was repeated, which showed disappearing of the lushendometritis detected in the previous study and slight reduction of the size of the bilateraltubo-ovarian lesion but still containing fluid (4).An endocervical biopsy was performed and showed a chronic/necrotising inflammation.DiscussionThe genitourinary tract is the most common site of extrapulmonary involvement of tuberculosis andfallopian tubes are affected in 94% of women with genital tuberculosis [2]. Salpingitis caused byhaematogenous dissemination is almost always bilateral [2] which explains that most women withgenital tuberculosis presents with infertility.Endometrial involvement is seen in 50% of the patients with tubal tuberculosis [1]. It can mimicovarian cancer by both radiologic findings and clinical settings; the symptoms are usually vague,serum CA-125 are usually elevated, and the radiologic findings closely resemble those ovariancancer with peritoneal seeding [1].A tubo-ovarian abscess that extends through the peritoneum into the extraperitoneal compartmentsuggests tuberculosis [2]. In addition to this cause, the extension to the retroperitoneum can also berelated to actinomyces infection [1].Peritoneal involvement in tuberculosis is present in 5% of cases and is usually associated withwidespread abdominal disease involving the lymph nodes or bowel. [3]. Nodal morphology, nodaldistribution, mesenteric nodularity, and omental caking are not useful to distinguish betweentuberculosis and peritoneal carcinomatosis because of considerable overlap.At MR imaging, the walls of tuberculous tubo-ovarian abscess are often irregular and show lowsignal intensity on T2-weighted images [1].Peritoneal tuberculosis can also be hypermetabolic on FDG PET, further mimicking peritonealcarcinomatosis [4].The definitive diagnosis of this pathological entity is made with tissue or fluid analysis and culture.Final DiagnosisGynaecological tuberculosisDifferential Diagnosis ListGranulomatous endometritis, Metastatic endometrial carcinoma, ActinomycosisFiguresFigure 1 Mediastinal enlarged lymph nodes:Computed Tomography of the thorax showingenlarged lymph nodes in mediastinum.: Area of Interest: Mediastinum; Thorax;  Imaging Technique: CT;  Special Focus: Infection; Inflammation; Figure 2 Computed Tomography findings:Increased volume of the adnexa withcentral hypodensity and peripheralenhancement. Major axis of the leftovary was 5.2 cm.: Area of Interest: Genital /Reproductive system female;  Imaging Technique: CT;  Procedure: Contrastagent-intravenous;  Special Focus: Inflammation; :Increased volume of the uterinecorpus with central hypodensityrevealing an endometrial lesion.: Area of Interest: Genital /Reproductive system female; Pelvis;  Imaging Technique: CT;  Procedure: Contrastagent-intravenous;  Special Focus: Inflammation; Figure 3 Magnetic Resonance findings:Sagittal T2-weighted image shows anheterogeeous thicker endometrium (arrow).: Area of Interest: Genital / Reproductivesystem female;  Imaging Technique: MR; :Sagittal T2-weighted image shows anheterogeeous thicker endometrium (arrow).: Area of Interest: Genital / Reproductivesystem female;  Imaging Technique: MR;  Special Focus: Inflammation; Figure 4 Post-treatment magnetic resonance imaging:Very good response to antituberculosis therapyinstituted. Currently, thin endometrium, withoutvisualization of the lesion of exuberantendometritis detected in the previous study.: Area of Interest: Pelvis;  Imaging Technique: MR; :Mild downsizing of bilateral tubo-ovarianabscesses, with some content liquid fillingboth tubes.: Area of Interest: Genital / Reproductivesystem female; Pelvis;  Imaging Technique: MR; MeSH [C13.371.056.750.249]EndometritisInflammation of the ENDOMETRIUM, usually caused by intrauterine infections. Endometritis isthe most common cause of postpartum fever. [C13.371.056.390.890]SalpingitisInflammation of the uterine salpinx, the trumpet-shaped FALLOPIAN TUBES, usually caused byascending infections of organisms from the lower reproductive tract. Salpingitis can lead to tubalscarring, hydrosalpinx, tubal occlusion, INFERTILITY, and ectopic pregnancy (PREGNANCY,ECTOPIC) [C13.371.803.940]Tuberculosis, Female GenitalTuberculosis of the genitalia in women. [C13.371.056.630.450]OophoritisInflammation of the OVARY, generally caused by an ascending infection of organisms from theendocervix.References[1] Kim SH, Kim SH, Yang DM et al (2004) Unusual causes of tubo-ovarian abscess. CT and MR Radiographics 24:1575-1589imaging findings[2] Engin G, Acuna B, Acuna G, Tunaci M (2000) Imaging of extrapulmonary tuberculosisRAdioGraphics 20:471-88[3] Tan CH, Kontoyiannis DP, Viswanathan C, Iyer RB (2010) Tuberculosis: a benign impostorAJR 194:555-61[4] Chen CJ, Yao WJ, Chou CY, et al (2008) Peritoneal tuberculosis with elevated serum CA125 Ann Nucl Med 22:525-527mimicking peritoneal carcinomatosis on F-18 FDG-PET/CTCitationBarbosa L, Cunha TM (2011, Sep. 12)  It seemed a terrible pelvic tumor... {Online}URL: http://www.eurorad.org/case.php?id=9341

It seemed a terrible pelvic tumor...

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It seemed a terrible pelvic tumor...

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