Intraperitoneal tuberculosis abscess in pregnancy presenting as an adnexal mass: a case report
Intraperitoneal tuberculosis abscess in pregnancy presenting as an adnexal mass: a case report
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DOI：
10.1080/01443615.2019.1679739
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发表时间：
2019-12-10
影响因子：
1.3
通讯作者：
Ocal, Pelin
中科院分区：
文献类型：
--
作者：
Erenel, Hakan;Alpay, Verda;Ocal, Pelin
腹膜内结核是一种腹部结核，发生于淋巴系统、网膜、肠道、肝脏、脾脏或女性生殖道和腹膜（Malik and Saxena Citation 2003）。仅占结核病病例1-2%的腹膜内结核可能表现为低热、腹痛、体重减轻、腹胀、CA-125水平升高、腹水和/或附件肿块（Wu et al. Citation 2011）。在妊娠期，腹膜内结核极为罕见，并且由于疾病的模糊症状和妊娠本身的临床影响，诊断通常延迟（Lee et al. Citation 2005）。妊娠期腹膜内结核表现为附件包块，由于症状相似，易误诊为恶性肿瘤。尤其是在发展中国家的孕妇，一旦发现附件包块，应怀疑腹腔结核脓肿。虽然腹腔镜检查或剖腹手术和活检是腹腔内结核病例的金标准方法，但可以对可疑病变进行计算机断层扫描和超声引导活检（Wu et al. Citation 2019）。我们首选超声引导活检，因为卵巢在MRI上是正常的，肿块被解释为脓肿或淋巴结来源的肿块。妊娠期腹膜内结核诊断后，应立即开始治疗，以预防先天性结核和产科并发症，如自然流产、早产和低出生体重（Loto和Awowole Citation 2012）。世界卫生组织建议使用乙胺丁醇、异烟肼、利福平和吡嗪酰胺2个月（强化阶段），然后使用异烟肼和利福平4个月（持续阶段）（世界卫生组织和遏制结核病倡议引文2010）。疾病控制和预防中心的指南不支持妊娠期使用吡嗪酰胺，因为其对胎儿的影响尚不清楚（疾病控制中心引文2003）。在我们的病例中，白细胞计数为13× 10 3/mm 3，在妊娠人群的正常范围内可接受（Lurie等人，Citation 2008）。在我们的病例中，CA-125水平在正常范围内也是可以接受的，因为CA-125水平在妊娠期也会升高（Bon et al. Citation 2001）。在存在附件肿块，不明确的症状和实验室检查结果，如在我们的情况下，医生可能会混淆这与卵巢癌。正常卵巢的可视化是至关重要的。这种临床方法可能会导致草率，不必要和广泛的手术，而结核病是一个高度治愈的疾病与抗结核治疗。
DiscussionIntraperitoneal tuberculosis is a form of abdominal tuberculosis that emerges from the lymphatic system, omentum, intestinal tract, liver, spleen or female genital tract and peritoneum (Malik and Saxena Citation 2003). Intraperitoneal tuberculosis which accounts only 1–2% of the cases of tuberculosis may present with low grade fever, abdominal pain, weight loss, abdominal distension, elevated CA-125 levels, ascites and/or adnexal mass (Wu et al. Citation 2011). In pregnancy, intraperitoneal tuberculosis is extremely rare and the diagnosis is usually delayed because of vague symptoms of the disease and the clinical effects of the pregnancy itself (Lee et al. Citation 2005). Intraperitoneal tuberculosis in pregnancy presented as an adnexal mass may be misdiagnosed as malignancy due to the similarity of the symptoms. Once an adnexal mass is encountered in a pregnant woman, especially in developing countries, intraperitoneal tuberculosis abscess should be suspected. Although laparoscopy or laparotomy and biopsy is the gold standard method in case of intraperitoneal tuberculosis, a computed tomography and ultrasound guided biopsy of suspicious lesions can be performed (Wu et al. Citation 2019). We preferred ultrasound guided biopsy since the ovaries were normal on MRI and the mass was interpreted as an abscess or a mass derived from lymph nodes. Following the diagnosis of the intraperitoneal tuberculosis in pregnancy, treatment should start immediately to prevent congenital tuberculosis and obstetric complications such as spontaneous abortion, preterm labour and low birth weight (Loto and Awowole Citation 2012). World Health Organisation recommends ethambutol, isoniazid, rifampicin and pyrazinamide for 2 months–the intensive phase–followed by 4 months of isoniazid and rifampicin–the continuation phase (World Health Organization and Stop TB Initiative Citation 2010). Centers for Disease Control and Prevention guidelines do not endorse pyrazinamide in pregnancy because its effect on the fetus is unknown (Centers for Disease Control Citation 2003). In our case, leukocyte count was 13× 10 3/mm 3 which is accepted within normal limits for pregnant population (Lurie et al. Citation 2008). CA-125 levels might also be accepted within normal limits in our case because CA 125 levels are also increased in pregnancy (Bon et al. Citation 2001). In the presence of an adnexal mass, unclear symptoms and laboratory findings like in our case, physician may be confused this with ovarian cancer. Visualisation of normal ovaries is crucial. This clinical approach may lead to hasty, unnecessary and extensive surgery, whereas tuberculosis is a highly curable disease with antituberculous treatment.