Isolated pelvic tuberculosis mimicking a gynecologic emergency: a case report and review of literature

Abstract

Introduction and importance:

Tuberculosis, an ancient disease caused by Mycobacterium tuberculosis, disproportionately affects low-socioeconomic countries. While pulmonary involvement is most common, extrapulmonary tuberculosis occurs in 10–20% of individuals. Among these, isolated pelvic tuberculosis is a rare presentation.

Presentation of case:

A 25-year-old mother from Garbo, Somali, Ethiopia presented with a 3-day history of lower abdominal pain, low-grade fever, nausea, and vomiting. She had regular menstrual cycles and resided in a rural, tuberculosis-endemic region. Examination revealed lower quadrant tenderness and a palpable 3 × 3 cm lower abdominal mass. Investigations showed mild anemia and ultrasound revealed a large, loculated pelvic fluid collection extensively filling the Pouch of Douglas and extending superiorly. GeneXpert testing of the aspirated fluid was positive for Mycobacterium tuberculosis. The patient initiated and completed anti-TB treatment, resulting in a full recovery without sequelae.

Clinical discussion:

Isolated pelvic tuberculosis, though typically presenting with chronic symptoms, can rarely manifest acutely, mimicking a gynecologic emergency as seen in this case. Dissemination occurs hematogenously or directly from nearby organs. Risk factors include patient factors like immunocompromization and environmental factors like poverty. Diagnosis requires a high index of suspicion, followed by imaging and confirmed bacteriological and histopathological examination. Treatment follows guideline-directed anti-TB therapy.

Conclusion:

Isolated pelvic tuberculosis, usually chronic, can rarely present acutely like a gynecologic emergency, demanding high suspicion. Early diagnosis and guideline-directed treatment are vital to prevent chronic complications and ensure favorable outcomes.

Introduction

Tuberculosis, an ancient disease caused by Mycobacterium tuberculosis, disproportionately affects low-socioeconomic countries^[1^]. Globally, tuberculosis impacted an estimated 10.6 million individuals in 2022, causing 1.3 million fatalities^[1^]. Although pulmonary involvement represents the predominant manifestation of tuberculosis, extrapulmonary forms are observed in approximately 10–20% of affected individuals^[2,3^]. While extrapulmonary tuberculosis (EPTB) often presents with concomitant pulmonary involvement, it can rarely manifest as isolated organ involvement, as observed in our patient with isolated pelvic tuberculosis^[4^]. Extrapulmonary tuberculosis presents with diverse clinical features based on the organ involved^[5^]. In female genital tuberculosis (FGTB), which our patient developed, presentations typically include chronic pelvic pain or a pelvic mass often confused with an ovarian tumor^[5^]. However, an acute presentation mimicking a gynecologic emergency, like that of our patient, is uncommon^[5^]. Prompt diagnosis and adherence to standard treatment, guided by national and WHO tuberculosis guidelines, are crucial to prevent chronic and irreversible complications, such as infertility^[1^].

HIGHLIGHTS

• Isolated pelvic TB is a rare form of genitourinary TB.

• Acute lower abdominal pain is an infrequent presentation of isolated pelvic TB, often mimicking a gynecologic emergency.

• The diagnosis of isolated pelvic TB requires gold-standard diagnostic tests, such as abdominopelvic CT and laparoscopic biopsy.

• However, in resource-limited settings where gold-standard diagnostic tests are often unavailable, diagnosing isolated pelvic TB requires a high index of suspicion.

• Confirmation in resource-limited settings is frequently achieved through ultrasound-guided aspiration for Mycobacterium tuberculosis (M.tb) identification.

• Early and proper treatment of isolated will prevent long-term complications like infertility.

We present the case of a 25-year-old para 3 woman, 7 months postpartum, from Garbo, Somali, Ethiopia, who presented with acute lower abdominal pain and was subsequently diagnosed with isolated pelvic tuberculosis. This atypical extrapulmonary manifestation in an immunocompetent individual offers valuable insight into similar diagnostic challenges in resource-limited settings.

This case report was prepared in accordance with the SCARE 2025 guideline^[6^].

Case presentation

A 25-year-old, para 3 (all alive) woman, 7 months postpartum from Garbo, Somali, Ethiopia presented to our facility with a 3-day history of lower abdominal pain. The pain was dull, aching, colicky, and bilateral, predominantly localized to the right lower quadrant. Associated symptoms included nausea, two episodes of non-bilious vomiting, and a low-grade fever. Her menstrual cycles were regular, with her last menstrual period occurring 20 days prior to presentation. She was not using any form of contraception. She had no history of vaginal discharge dyspareunia, vaginal itching, bleeding, failure to conceive or multiple sexual partner history. Notably, the patient resided in a rural, tuberculosis endemic region of Ethiopia. Her medical history was otherwise unremarkable, with no known chronic illnesses. She denied a history of diarrhea, changes in mentation, failure to pass feces or flatus, or urinary complaints. There was also no history of cough, significant weight loss, loss of appetite, night sweats, or any other site of swelling. She had no known contact history of known TB patient or her partner is healthy with no identified health problem.

On initial physical examination, the patient was conscious, acutely ill-appearing, and not in respiratory distress. Vital signs revealed tachycardia (pulse 110–116 bpm) and a low-grade fever (37.8 °C), with other vital signs within normal limits. Abdominal examination revealed tenderness on both superficial and deep palpation in the lower quadrants. A 3 × 3 cm soft-to-firm, non-mobile mass was palpable in the lower abdomen, without overlying skin changes. Liver and spleen were not palpable. Other systemic examinations were unremarkable.

Given the initial impression of an acute gynecologic emergency, intravenous fluids were initiated, and investigations were sent. Laboratory findings included a complete blood count showing a white blood cell count of 6.5 × 10⁹/l with 70% neutrophils, a hemoglobin of 10.2 g/dl with a microcytic mean corpuscular volume (MCV 65 fL), and a platelet count of 234 × 10⁹/l. Urinalysis and stool analysis were unremarkable, and urine beta-human chorionic gonadotropin (hCG) was negative. Serologies for VDRL, HBsAg, and HIV were negative. Creatinine was 0.65 mg/dl. A chest X-ray was reported as normal.

Abdominopelvic ultrasound revealed a large (12 × 11 cm), loculated pelvic fluid collection extensively filling the Pouch of Douglas and extending into the uterovesical and supravesical spaces. The collection demonstrated thick, irregular, enhancing walls, without internal septations or solid components as shown in Figure 1. Other abdominal organs appeared normal.

Figure 1.

Trans-abdominopelvic ultrasound image showing a large, loculated pelvic fluid collection extensively filling the Pouch of Douglas (cul-de-sac) and extending into the uterovesical and supravesical spaces.

Based on the ultrasound findings, a diagnosis of a large, loculated pelvic fluid collection was made. A reproductive-aged female presented acutely, without chronic symptoms, prompting an initial impression of an acute gynecologic emergency. Differential diagnoses included ectopic pregnancy, ruptured ovarian cyst, and tubo-ovarian abscess. However, urine HCG was negative, and the patient had no identified risk factors for pelvic inflammatory disease. Due to resource constraints, abdominopelvic CT could not be performed. Therefore, considering the local epidemiology, an ultrasound-guided fluid aspiration was undertaken. GeneXpert testing on the aspirate was positive for Mycobacterium tuberculosis, with no resistance to rifampicin detected. However, due to resource constraints, cytology for malignancy and other cancer markers could not be performed, as these diagnostic capabilities were unavailable. Despite these limitations, ovarian malignancy remained a differential diagnosis. Ultimately, the complete resolution of the abscess supported a diagnosis of pelvic tuberculosis.

Consequently, a definitive diagnosis of isolated pelvic tuberculosis was established. The patient was initiated on a standard 6-month anti-tuberculosis regimen [2 months of Rifampicin, Isoniazid, Pyrazinamide, Ethambutol [RHZE] followed by 4 months of Rifampicin and Isoniazid (RH)], supplemented with pyridoxine, as per national and WHO guidelines. She was meticulously monitored for drug adherence, side effects, and clinical response.

Follow-up ultrasound at 1 month showed a significant decrease in the fluid collection, which completely resolved by the end of the second month of treatment. She successfully completed the full 6-month regimen in October 2025. The patient remains well, was counselled regarding future reproductive planning, and has been discharged from follow-up. Given the nature of the abscess as a “cold abscess,” antitubercular treatment generally suffices, obviating the need for surgical intervention^[7^]. Surgical indications for such abscesses typically include ruptured abscess, failed response to treatment, diagnostic uncertainty, persistent pelvic mass, and multidrug-resistant tuberculosis (MDR-TB)^[7^]. As none of these indications were present in our patient, surgical intervention was deemed unnecessary^[7^].

Discussion

Isolated pelvic tuberculosis, as demonstrated by our patient, is a rare form of extrapulmonary tuberculosis that typically presents with chronic symptoms. However, an acute presentation mimicking a gynecologic emergency, as seen in this case, is exceedingly uncommon. Genitourinary tuberculosis is the second most common form of extrapulmonary tuberculosis, following lymph node involvement^[8^]. However, isolated genital TB is rare, accounting for only 9% of GUTB cases^[8^].

The dissemination of female genital tuberculosis is multifactorial^[8,10^]. The most common route of tuberculosis dissemination is hematogenous spread from a primary focus elsewhere in the body^[8,9^]. Other potential pathways include direct ascending spread from the lower genital tract to the upper reproductive organs, or descending spread from contiguous structures^[9,10^]. Furthermore, TB can spread from adjacent gastrointestinal involvement to affect nearby reproductive organs^[9^]. In our patient’s case, however, neither lymph node nor intestinal involvement was identified on abdominopelvic ultrasound, and a colonoscopy was not performed. Importantly, there was no identifiable primary pulmonary focus.

The risk factors for female pelvic tuberculosis align with those for other TB manifestations^[8,11^]. Intrinsic factors include advanced age, comorbidities, and acquired or inherited immune-compromization, while extrinsic factors encompass poverty and residence in high TB endemic regions^[8,11^]. Although our patient lived in a rural, high TB burden country, no intrinsic risk factors were identified.

The clinical presentation of female pelvic tuberculosis is variable and often chronic, commonly mimicking ovarian malignancy^[8,12,13^]. Patients may present with ascites, adnexal masses, weight loss, anorexia, fever, and night sweats^[12^]. Other patients experience gynecological complaints such as vaginal discharge, amenorrhea or menorrhagia, depending on the site of involvement^[12,14^]. Female pelvic tuberculosis can also lead to infertility, either primary or secondary, due to tubal, ovarian, endometrial, or combined of it from hormonal or mechanical factors^[8,14^]. In contrast, our patient presented with an acute manifestation and no identified complications; she is a para 3 mother with no history of previous abortion or conception failure.

In Ethiopia, recent case reports from 2025 highlight diverse presentations of female genital tuberculosis. Tebeje et al described a case of tubo-ovarian tuberculosis in a multiparous 40-year-old female presenting acutely with abdominal pain, similar to our patient. However, their patient also exhibited ascites and subsequently had an abortion^[15^]. Another case from a different area involved a 20-year-old nulliparous Ethiopian woman who presented with a long-standing history of abdominal swelling, fever, and significant ascites^[16^].

Diagnosing female genital tuberculosis requires a high index of suspicion due to its nonspecific manifestations. Patients often present with symptoms leading to evaluation for other conditions, such as infertility workup, benign cysts, or malignancy^[11,17,18^]. Initial ultrasonography, the primary imaging modality in many settings, may reveal structural lesions affecting the female genital organs, including pyosalpinx, endometrium, or adnexal involvement^[11,17,18^]. While advanced imaging like abdominopelvic MRI or CT and tissue biopsy (image-guided or laparoscopic) are standard for definitive diagnosis and to rule out malignancy, our patient’s diagnosis was established solely through ultrasound-guided fluid aspiration, which tested positive for Mycobacterium tuberculosis by GeneXpert. The diagnostic certainty of various modalities fluctuates depending on the clinical context^[14^]. While ultrasound, CT, and MRI are useful, they possess low specificity as they often fail to differentiate ovarian malignancy from a tuberculous abscess^[19,20^]. Although ultrasound-guided biopsy can improve diagnostic yields, it was not feasible in our setting due to a lack of specialized equipment and pathological services^[21^]. Instead, we performed ultrasound-guided aspiration; while this method typically has lower sensitivity for Mycobacterium tuberculosis detection and cytology, it yielded a positive GeneXpert result in our case^[19,20^]. In contrast, resource-rich centers often utilize laparoscopic-guided biopsy, which provides over 97% sensitivity and specificity, yet this remained inaccessible due to resource constraints^[20,21^]. Furthermore, the absence of laboratory tumor markers like CA-125 in resource-limited setups adds another layer of complexity^[19^]. Although CA-125 is non-specific and can be elevated in both pelvic TB and peritoneal inflammation, it remains a helpful, albeit imperfect, diagnostic adjunct when available^[19^]. Advanced imaging and laparoscopy were not feasible due to resource limitations^[11,17^]. Following completion of tuberculosis treatment, referral for infertility evaluation, including procedures like hysteroscopy, is typically recommended. However, our patient was unable to afford this referral^[17,18^]. We advised her on potential future assessment for infertility if conception difficulties arise, alongside recommendations for nutritional support and family planning.

Once diagnosed, uncomplicated pelvic tuberculosis is treated straightforwardly with anti-tuberculosis therapy, following updated national and WHO recommendations (2RHZE/4RH regimen with pyridoxine supplementation)^[8,17^]. Our patient was initiated on this regimen and diligently followed for adherence, treatment response, and drug side effects, successfully completing her anti-tuberculosis therapy without adverse effects^[8^]. However, unlike our patient, some individuals may develop structural scarring and genitourinary sequelae requiring hysteroscopy and subsequent specialized treatment^[22^]. Our patient reported no such complications and is currently doing well. She was advised to seek referral for infertility evaluation if she experiences difficulty conceiving, with additional recommendations for nutritional support and family planning.

Conclusion

Isolated pelvic tuberculosis is a rare extrapulmonary manifestation of genitourinary TB. Although pelvic tuberculosis typically follows a chronic course with varied manifestations, it can occasionally present acutely with lower abdominal pain. In such instances, it may mimic gynecological emergencies – such as ectopic pregnancy or ovarian torsion – as demonstrated in our patient. In resource-limited settings, a high index of suspicion is essential. When gold-standard diagnostic tests (e.g., abdominopelvic CT, laparoscopic biopsy) are unavailable, leveraging available infrastructure, such as ultrasound-guided aspiration, becomes crucial for diagnosis. Prompt diagnosis using these accessible methods, followed by guideline-directed treatment, is vital for achieving favorable patient outcomes and preventing chronic complications like infertility. Enhancing diagnostic capacity – including laparoscopic and ultrasound‑guided biopsy, expanded laboratory testing for tumor markers, and strengthened preventive/screening measures – is essential for earlier diagnosis and to reduce misdiagnosis.

Strengths and limitations

Strengths

This case report uniquely highlights the acute presentation of isolated pelvic tuberculosis (IPTB) in an immunocompetent individual, a rare manifestation. Originating from a resource-limited setting, this report offers valuable clinical insights and raises awareness for healthcare providers in similar environments, potentially facilitating earlier diagnosis and timely management.

Limitations

A primary limitation was the unavailability of advanced imaging modalities such as abdominopelvic MRI and CT scans, which could have provided more detailed anatomical assessment and differentiation from other pathologies. Furthermore, a definitive diagnosis via laparoscopic tissue biopsy, often considered the gold standard for pelvic tuberculosis, could not be performed due to the same resource constraints.

Declaration of generative AI and AI-assisted technologies in the writing process

AI language modelling tools were utilized for the improvement of English-language only in this case report.

Ethical approval

Ethical approval for this study was provided by our institution ethical review committee.

Consent

Written informed consent was obtained from the patient for publication and any accompanying images. A copy of the written consent is available for review from the Editor-in-Chief of this journal on request.

Sources of funding

There is no source of funding for this paper.

Author contributions

A.A.A.: conceptualization, design of the study, acquisition of data, drafting the article, revising it critically for important intellectual content, approval of the version to be submitted; T.G.A.: analysis, interpretation of data, drafting the article, revising it critically for important intellectual content, approval of the version to be submitted; W.A.N.: conceptualization, analysis, drafting the article, revising it critically for important intellectual content, approval of the version to be submitted; T.S.M.: acquisition of data, analysis, revising it critically for important intellectual content, approval of the version to be submitted; M.A.I.: acquisition of data, analysis, revising it critically for important intellectual content, approval of the version to be submitted; A.A.M.: acquisition of data, analysis, revising it critically for important intellectual content, approval of the version to be submitted.

Conflicts of interest disclosure

All authors declare that they have no conflict of interest.

Research registration unique identifying number (UIN)

Not applicable.

Guarantor

Addisu Assfaw Ayen.

Provenance and peer review

Not commissioned; externally peer-reviewed.

Data availability statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.