two cases of miliary tuberculosis and elevated levels of

Can J Infect Dis Med Microbiol Vol 17 No 2 March/April 2006 135

LETTER TO THE EDITOR

Two cases of miliary tuberculosisand elevated levels of cancerantigen 125

Ovarian carcinoma is one of the most dangerous malig-nancies in women. The serum level of cancer antigen(CA) 125, as a tumour marker, is useful in the diagnosis ofovarian cancer. CA 125 serum level is also elevated inascites (1), ovarian tube abscess (2,3), biliary duct cancer and periampullary tumours (4), cholangitis (5),cancer of pancreas (6) and cervical adenocarcinoma (7).Additionally, sometimes the serum level of CA 125increases spontaneously during the menstrual cycle (8,9).In bone marrow transplantation, this marker is a sensitiveindex in the diagnosis of veno-occlusive disease (10). Wedescribe an elevated serum level of CA 125 in two cases oftuberculosis (TB): one with cryptogenic miliary TB, andthe other with miliary TB and meningitis.

The first patient was an 80-year-old woman originallyfrom a city in northeast Iran, but residing in Tehran. Shepresented with weight loss (10 kg within a five-monthperiod), weakness, fatigue and alteration in bowel habits.Her history included only arterial hypertension andcoronary artery disease. Physical examination was normal.

Complete blood count biochemistry and thyroid func-tion was normal. The erythrocyte sedimentation rate was55 mm. All C3, C4 and CH50 tests were normal, as wererheumatoid factor and antinuclear antibodies. Tumourmarkers for carcinoembryonic antigen, CA 15-3 andCA 19-9 were normal, but the CA 125 serum level wasmore than 130 U/mL (normal range 0 U/mL to35 U/mL).

Further negative investigations included blood cul-tures, radiography of the maxillofacial area, spinal columnand sinuses, colonoscopy and barium enema, whole-bodyscan, abdominal and pelvic sonography, and computedtomography (CT) scan. Gynecological evaluationshowed only atrophic vaginitis.

Bone marrow biopsy revealed a granulomatous inflam-mation with caseification necrosis, compatible with TB.The patient was diagnosed with cryptogenic miliary TBand placed on isoniazid, rifampin, ethambutol and pyrazi-namide. At the end of the second month of therapy, thepatient’s CA 125 serum level had returned to normal. Shereceived isoniazid and rifampin alone from the beginningof the third month, and remains cured.

The second patient was a 25-year-old woman fromHamedan, Iran, who presented with fatigue, weakness,loss of appetite and hemoptysis.

Loss of consciousness and obtundation occurred onthe day of admission, and she progressed to deep comawithin 4 h.

Brain CT scan showed no space-occupying lesion,but a chest radiograph revealed a diffuse miliary pattern.Lumbar puncture showed cerebrospinal fluid compatiblewith chronic meningitis, and a direct smear of

cerebrospinal fluid showed acid-fast bacilli. CT of theabdomen and pelvis was normal. The CA 125 serum levelwas dropped from 113 U/mL on the first day of admis-sion, and declined to 18 U/mL two months after initia-tion of treatment.

There is one other report of a patient with TB and ele-vated serum level of tumour markers. Rao et al (10)reported a patient with TB of the genital tract and an ele-vated level of serum CA 125. This patient presented withgastrointestinal signs and symptoms. The patient’s CA125 serum level was elevated at 163.1 U/mL, CA 19-9was elevated at 54.1 U/mL, and para-aortic lym-phadenopathy strongly suggested malignancy. Biopsy ofovaries, however, revealed granulomatous inflammation.

CA 125 is a glycoprotein existing on the surface of ovar-ian cells and other types of cells. Usually, an antigen levelof over 35 U/mL is abnormal and warrants investigation.Tissue destruction releases CA 125 into serum, and suc-cessful treatment is associated with a decline in the serumlevel of this antigen.

These two cases show that CA 125 and some othertumour markers may increase in miliary TB. In bothpatients, successful treatment led to normalization of theCA 125 level.

M Alimagham, S Aminiafshar, SMM Hosseini Moghaddam, S Shokuhi,

Shaheed Beheshti University of Medical Sciences, Tehran, Iran

REFERENCES1. But I, Reljic M. The value of serum CA 125 for the

management of tubo-ovarian abscesses. Wien Klin Wochenschr 2000;112:1044-8.

2. Gungor T, Parlakyigit EE, Dumanli H. Actinomycotic tubo-ovarian abscess mimicking pelvic malignancy. Gynecol ObstetInvest 2002;54:119-21.

3. Chen CY, Shiesh SC, Tsao HC, Lin XZ. The assessment of biliaryCA 125, CA 19-9 and CEA in diagnosing cholangiocarcinoma –the influence of sampling time and hepatolithiasis.Hepatogastroenterology 2002;49:616-20.

4. Ng WW, Tong KJ, Tam TN, Lee SD. Clinical values of CA19-9,CA125 and CEA in malignant obstructive jaundice. Zhonghua YiXue Za Zhi (Taipei) 1995;55:438-46.

5. Gattani AM, Mandeli J, Bruckner HW. Tumor markers in patientswith pancreatic carcinoma. Cancer 1996;78:57-62.

6. Gadducci A, Cosio S, Carpi A, Nicolini A, Genazzani AR. Serumtumor markers in the management of ovarian, endometrial andcervical cancer. Biomed Pharmacother 2004;58:24-38.

7. Mylonas I, Makovitzky J, Richter DU, Jeschke U, Briese V,Friese K. Immunohistochemical expression of the tumour markerCA-125 in normal, hyperplastic and malignant endometrial tissue.Anticancer Res 2003;23:1075-80.

8. Sevinc A, Camci C, Turk HM, Buyukberber S. How to interpretserum CA 125 levels in patients with serosal involvement? A clinical dilemma. Oncology 2003;65:1-6.

9. Petaja J, Pitkanen S, Vettenranta K, Fasth A, Heikinheimo M.Serum tumor marker CA 125 is an early and sensitive indicator ofveno-occlusive disease in children undergoing bone marrowtransplantation. Clin Cancer Res 2000;6:531-5.

10. Rao GJ, Ravi BS, Cheriparambil KM, Pachter B, Pujol F.Abdominal tuberculosis or ovarian carcinoma: Managementdilemma associated with an elevated CA-125 level. MedscapeWomens Health 1996;1:2.

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