Isolated Ovarian Tuberculosis Mimicking Ovarian Malignancy in a Young Female with Primary Infertility: A Case Report

Abstract

Background

Tuberculosis (TB) is an infectious disease that most commonly affects the lungs and remains among the top 10 causes of death worldwide. Isolated ovarian tuberculosis is a rare form of extrapulmonary TB that usually presents with atypical symptoms and infertility. It brings significant diagnostic challenges and may mimic ovarian malignancy.

Case Presentation

A 23-year-old nulliparous Afghan woman underwent laparotomy for suspected ovarian adnexal masses/ovarian tumor after presenting with pelvic pain, prolonged low-grade fever, and infertility for five years following marriage. Intraoperatively, bilateral ovarian cysts were noted; subsequently, bilateral cystectomies were done. Postoperative Histopathology of surgical specimens confirmed the diagnosis of tuberculosis lesions, and the patient was referred for anti-tuberculous therapy.

Conclusion

Isolated ovarian tuberculosis can present as adnexal masses with elevated CA-125 and could closely mimic ovarian malignancy. This case highlights the need to consider ovarian tuberculosis in the differential diagnosis, particularly in endemic regions. It emphasizes the value of histopathological confirmation to prevent misdiagnosis and to recommend early initiation of antitubercular therapy for favorable clinical outcomes.

Introduction

Tuberculosis (TB) remains a major global health challenge, particularly within developing and low-resource countries. According to the World Health Organization (WHO), an estimated 10.7 million people developed TB in 2024, including 5.8 million men, 3.7 million women, and 1.23 million children.¹ TB is the world’s leading cause of death from a single infectious agent, among the top 10 causes of death, and presents in all countries and age groups.¹ Afghanistan remains a high-TB-burden country, with an incidence of about 204 cases per 100,000 in 2024 due to prolonged sociopolitical instability, malnutrition, and a fragile healthcare infrastructure.¹

Female Genital tuberculosis (FGTB) could happen secondary to pulmonary TB or extrapulmonary foci such as the meninges, kidneys, skeletal system, and gastrointestinal system. TB bacilli infect the genital system by four routes: hematogenous route, lymphatic spread, descending direct spread, and rarely as a primary infection of the female genitalia through sexual transmission.² FGTB predominantly affects reproductive-age women and is counted as an important cause of infertility in endemic regions.²

Isolated ovarian tuberculosis sparing the fallopian tubes and endometrium is a clinical rarity.³ Because of its nonspecific clinical presentation combined with complex adnexal masses and elevated serum Cancer Antigen 125 (CA-125) levels, ovarian tuberculosis frequently mimics advanced epithelial ovarian malignancy.³ This Diagnostic overlap represents a critical clinical challenge, and misinterpreting ovarian tuberculosis as ovarian carcinoma often leads to aggressive surgical intervention such as pelvic clearance, resulting in irreversible loss of reproductive potential.^3,4 Infertility is estimated to effect 60–80% of women with FGTB most women with FGTB have minimal or no clinically obvious symptoms, and many are identified only during work-up for infertility.^2,4 In FGTB, granulomatous inflammation and caseous necrosis lead to tubal fibrosis and causing obstruction of fallopian tubes, inadequate endometrial receptivity due to intrauterine adhesions, and less commonly inflammatory destruction of ovarian tissue leading to defective ovarian reserve, which together debilitate oocyte release, fertilization, and implantation.^2,4 We report a rare case of isolated ovarian tuberculosis in a 23-year-old nulliparous Afghan woman presenting with bilateral adnexal masses, primary infertility, elevated CA-125, and anemia.

Case Presentation

A 23-year-old nulliparous Afghan woman presented with a four-month history of lower abdominal/pelvic pain accompanied by a six-month history of low-grade intermittent fever, anorexia, and malaise. She also reported primary infertility for five years despite regular unprotected intercourse following marriage. She denied cough, dyspnea, night sweats, or weight loss. Menstrual cycles were regular with no history of dysmenorrhea or abnormal uterine bleeding. There was no personal or family history of tuberculosis. On general examination, the patient was conscious, alert, and oriented. She was afebrile at presentation with a temperature of 37.1°C, blood pressure 110/60 mmHg, pulse rate 88 beats/min, respiratory rate 18 breaths/min, and oxygen saturation 96% on room air. Systemic examination was unremarkable. Except on bimanual pelvic examination, an approximately 7.5 × 6 cm mass was palpated in the right adnexa. Speculum examination displayed normal vaginal mucosa and cervix, with no abnormal vaginal discharge or cervical lesions. Laboratory investigations were performed, including complete blood count (CBC), urine biochemistry, serum CA-125, serological testing, chest radiography, and abdominopelvic ultrasonography. The Hemoglobin level was 10.9 g/dL, total leukocyte count was 9.2 × 10⁹/L, and platelet count was 374 × 10⁹/L. Urinalysis was unremarkable. Serological testing for HIV, HCV, and pregnancy β-hCG (Beta Human Chorionic Gonadotropin) was negative. The Serum CA-125 level was elevated to 117 U/mL (reference range: <35 U/mL). Chest radiography (Figure 1) showed no radiological evidence of pulmonary tuberculosis or other significant abnormalities. Abdominopelvic ultrasonography revealed bilateral complex adnexal masses measuring 8 × 6cm in the right ovary and 3 × 4 cm in the left ovary with regular margins. Based on the imaging findings and elevated CA-125 level, ovarian malignancy was considered among the differential diagnoses. The patient subsequently underwent exploratory laparotomy. Intraoperatively, pathological findings were confined to the adnexa. An 8 × 6 cm cyst was identified in the right ovary, while a 3 × 4 cm cyst was noted in the left ovary. There was no gross evidence of peritoneal deposits, tubal involvement, ascites, or other intra-abdominal pathology. Bilateral ovarian cystectomy was successfully performed, and the postoperative course was uneventful. Gross pathological examination revealed a gray-white ovoid cystic mass measuring 8 × 8 × 6 cm in aggregate. The bisected specimen shows a thickened cyst wall containing internal fibrosis septation (Figure 2). Microscopic examination demonstrated extensive caseous necrosis with granulomatous inflammation composed of epithelioid histocytes, multinucleated giant cells, and dense chronic inflammatory infiltrates predominantly consisting of lymphocytes (Figure 3A and B). No evidence of dysplasia or malignant cells was identified in the examined sections. The histopathological findings were consistent with tuberculosis, and a final diagnosis of isolated ovarian tuberculosis was established. The patient was subsequently referred to the infectious disease service and commenced on six-month standard anti-tuberculous therapy. At six-month follow-up, the patient had complete resolution of abdominal pain, fever, malaise, and anorexia, following completion of anti-tubercular therapy. Hence, further tumour-marker monitoring was not considered necessary at that time. However, pregnancy had not yet been achieved, and continuation of gynecological follow-up was recommended.

Figure 1.

Chest X-ray of patient’s lungs.

Figure 2.

Gross appearance of the right ovarian cyst following cystectomy. The bisected cystic specimen demonstrates a thickened wall with internal fibrosis septation. The specimen measured approximately 8 × 8 × 6 cm in aggregate.

Figure 3.

(A and B) Histopathological findings of ovarian tuberculosis. (A) Microscopic examination demonstrates multiple well-formed granulomas composed of epithelioid histocytes, some exhibiting central caseous necrosis with surrounding lymphocytic infiltrate and stromal fibrosis. (B) Microscopic finding of the same pathology at a different field/magnification showing numerous Langhans giant cells and granulomas with central caseation and surrounding lymphocytic infiltrate.

Discussion

WHO reported 1.23 million deaths from TB in 2024.¹ About one-fourth of the global population has been infected with TB bacteria, and 5–10% of those infected develop TB disease in their lifetime.¹ Patients with immunosuppressive conditions such as HIV/AIDS face an elevated risk of progressing to the disease, specifically abdominal and pelvic TB.^5,6 Additional risk factors that predispose patients to TB include low-income status and restricted access to health care services.⁵ In our case, HIV serology was negative, but the patient had a low income and limited healthcare access.

Globally, extra-pulmonary tuberculosis accounts for 10% of all cases.⁷ Female genital tuberculosis (FGTB) significantly contributes to substantial morbidity, particularly infertility and persistent pelvic pain. However, due to the asymptomatic nature of the disease in a minimum of 11% of patients, its diverse clinical presentations, and frequent incidental diagnoses, the precise incidence of genital TB remains challenging to quantify.^7,8 The dissemination of the pathogen commonly occurs after puberty, particularly between the ages of 20 and 40 years, when the vascular supply to the genital organs increases, promoting the transmission of bacilli within the pelvic region. Consequently, a greater number of microorganisms reach and involve this area.^9,10

In FGTB, the fallopian tubes are the most frequently involved structures (95–100% of cases), followed by the endometrium (50–60% of cases), ovaries (20–30% of cases), cervix (5–15% of cases), and the uterus (2.5%).⁷ The fallopian tubes and endometrium are nearly always affected, whereas isolated ovarian involvement, as observed in our case, is infrequently reported.⁷ Pulmonary tuberculosis may precede ovarian involvement; however, in our patient not observed, as illustrated by our case.⁷

Clinical manifestations of female genital tuberculosis are variable, and some patients may remain completely asymptomatic. Previous studies have shown that approximately 11–40% of affected women have no apparent symptoms and are often diagnosed only during investigations performed for infertility.^5,10,11 Among symptomatic patients, the four main presenting complaints are infertility, abnormal uterine bleeding, pelvic pain, and amenorrhea.⁸ In 50% of FGTB cases, physical examinations could be normal. With little correlation between examination findings and symptoms. Abnormal findings generally include signs of ascites or adnexal masses.⁹ In this case, the patient presented with primary infertility and pelvic pain.

Genital TB is challenging to diagnose for several reasons. Firstly, genital TB is frequently asymptomatic, leading to considerable delays in diagnosis. Secondly, its clinical presentation resembles that of other gynecological malignancies, including ovarian carcinoma.¹² Laparoscopy represents a significant advancement in the diagnosis of TB, achieving over 97% accuracy while avoiding laparotomy.⁵ However, it was not carried out in our patient because of the suspicion of ovarian carcinoma and the relatively large size of the bilateral adnexal masses. In this setting exploratory laparotomy was performed to allow complete assessment, safe excision, and minimize the risk of tumour spillage. During exploratory laparotomy, differentiating pelvic TB from ovarian malignancy may be difficult, as their gross appearances can be comparable. Intraoperative frozen section analysis may be useful in distinguishing pelvic TB from malignancy in patients undergoing surgery for tubo-ovarian masses, particularly in endemic regions.⁹ Nevertheless, this procedure was also not performed in our patient. The definitive diagnosis of TB can only be established by detecting the organism on LJ medium or through acid-fast staining.^10,13 However, UGTB commonly presents in a pauci-bacillary form, and consequently, approximately one-third of cultures are negative.^7,13,14 According to Namavar et al, the diagnosis of genital TB may be established by characteristic histopathological findings, particularly the presence of typical granulomatous lesions.¹⁵ In our case, histopathology confirms the diagnosis with its exact findings of tuberculosis, but acid-fast staining was not available.

Radiological imaging could help in FGTB evaluation; however, its findings are not specific and may be closely misdiagnosed as other gynecological conditions, particularly epithelial ovarian malignancy. Imaging findings may include complex adnexal masses, hydrosalpinx, tubo-ovarian lesions, pelvic adhesions, ascites, peritoneal thickening, and lymphadenopathy.^2,4,5 Therefore, imaging modalities such as ultrasonography, hysterosalpingography, computed tomography, and magnetic resonance imaging are valuable for disease assessment but not sufficient for definitive diagnosis without histopathological or microbiological confirmation.^2,4,5 In this case, ultrasonography demonstrated bilateral complex adnexal masses and contributed to the initial suspicion of ovarian malignancy. Chest radiography is used to identify pulmonary TB infection; findings could include healed TB lesions, hilar lymphadenopathy, fibrosis, opacities, and effusions. Despite this, many patients with genital tuberculosis have normal chest radiographs because genital involvement often results from hematogenous dissemination occurring years after the primary pulmonary focus has healed.^2,4,7 In our patient, chest radiography was normal despite histopathological confirmation of ovarian tuberculosis, so a normal chest x-ray should not be used to exclude the FGTB. Nevertheless, a limitation of the present case should be acknowledged. Magnetic resonance imaging (MRI) was not performed due to patient-related constraints.

As TB is known to present with pelvic masses, ascites, and elevated CA-125 levels, clinicians should consider TB among other differential diagnoses such as fallopian tube or ovarian carcinomas, particularly in endemic areas.⁹ In cases of ovarian TB, CA-125 levels rarely exceed 500 U/mL, as observed in our patient, who had a level of 117 U/mL. Increased CA-125 levels can be observed in other malignancies, including mesothelioma, breast cancer, gastrointestinal leiomyosarcoma, non-Hodgkin lymphoma, leiomyoma, and gastric cancer. CA-125 may also be elevated in several benign conditions.⁷ These include pregnancy, ovulatory cycles, endometriosis, congestive heart failure, and liver disease. However, in these cases, the value shouldn’t exceed 500 IU/mL.^7,9 CA-125 may also be used as a follow-up marker in peritoneal or genital TB, as its normalization is associated with response to anti-tuberculous therapy.⁷ Simsek et al observed that decreasing CA-125 levels are associated with gradual improvement of the disease during treatment, indicating that serial CA-125 monitoring may be useful for assessing treatment response.^5,16 Moreover, human epididymis protein 4 (HE4) demonstrates greater specificity compared with CA-125 as a marker in benign conditions.¹⁷ However, tuberculosis, a relatively common infectious disease, should always be considered in patients presenting with suspected malignancy or pelvic masses, particularly in endemic regions, to avoid unnecessary invasive procedures and related complications.⁷ In addition, in a young reproductive age woman presenting with an adnexal mass, ovarian germ cell tumor should also be included in the differential diagnosis alongside epithelial malignancy and tuberculosis; tumor markers measurement such as alpha-fetoprotein (AFP) and beta-human chorionic gonadotropin (β -hCG), in conjunction with lactate dehydrogenase(LDH), can help confined this differential diagnosis preoperatively.¹⁸

The World Health Organization recommends that female genital tuberculosis (FGTB) be managed with an intensive phase consisting of daily ethambutol, isoniazid, rifampicin, and pyrazinamide for 2 months, followed by a continuation phase of daily isoniazid and rifampicin for 4 months.¹ Surgical intervention generally reserved for cases unresponsive to medical therapy, including procedures like removal of large tubo-ovarian abscesses and drainage of pyosalpinx, followed by anti-tuberculous therapy to achieve better outcomes.⁸ The prognosis of pelvic tuberculosis is mainly associated with infertility, which has been estimated to affect approximately 39% of young women, as seen in our case also.¹⁴ Early recognition of the disease and timely initiation of appropriate therapy are crucial to ensure a favorable prognosis.⁷

This case illustrates the epidemiology of TB, the anatomical distribution of FGTB, clinical manifestations, diagnostic challenges and differential diagnosis, CA-125, anti-tuberculous therapy, and outcomes.

Conclusion

Isolated Ovarian Tuberculosis remains a rare extrapulmonary manifestation of TB; it should be considered in the differential diagnosis in women presenting with complex adnexal masses, atypical imaging, and elevated CA-125 levels in endemic regions.

This case further highlights the importance of histopathological examination for establishing an early diagnosis, initiating anti-tuberculous therapy for favorable clinical outcomes, and preventing radical pelvic surgeries.

Funding Statement

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Data Sharing Statement

The manuscript has no associated data.

Ethics Approval and Consent to Participate

Ethical approval was not required for this case report in accordance with institutional guidelines. Written informed consent was obtained from the patient for publication of this case report and any accompanying images.

Disclosure

The authors declare that they have no competing interests.