clinical pathological conference may 11, 2007. chief complaint: 51 year old female with abdominal...
TRANSCRIPT
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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:Meig’s syndromeAntiphospholipid syndromePseudomyxoma 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 dependantlobe: primary focus
Early lymphohematogenousspread
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