A 21-year-old sexually virgin female was referred to Surgical Oncology out patient in June 2020 with provisional diagnosis of epithelial ovarian malignancy on the basis of MRI findings and raised CA125 level of 129.8 U/ml (normal 0–35). On enquiring, she had irregular menstruation for last 6 months, abdominal distension for 2 months and pain in lower abdomen for last 1 month. She had a past history of cervical lymph node tuberculosis in 2017, for which she completed anti tubercular therapy for 18 months with standard regimen of isoniazid, rifampicin, pyrazinamide, and ethambutol. Other than this there was no significant medical and surgical history. Personal and family history was noncontributory. On clinical examination, general condition was fair, vitals were stable, systemic examination was normal. On per abdomen examination, patient had mild tenderness in the lower abdomen with no signs of guarding, rigidity or free fluid in the abdomen. No definite mass or lump was palpable.
Her previous MRI scan was reviewed which showed extensive smooth peritoneal thickening with moderate ascites, multiloculated cystic lesion in bilateral adnexa, variably hyperintense on T2 weighted MRI and variably hyperintense to hypointense on T1 weighted images, the lesions were in close relation with ovaries but bilateral ovaries were normally visualized (Fig. 1). This suggested possibility of tubo-ovarian origin of the mass. Her routine biochemical blood investigations were within normal limit except for raised ESR 32mm/hr (normal 0–20). Other tumor markers were also with in normal limit, LDH- 216 U/L (normal 135–225), alpha fetoprotein-1.6 ng/ml (normal 0.89–8.78), serum CEA < 0.5 ng/ml (normal 0–5), beta HCG < 2 mIU/ml (normal 0–5). Seeing her past history of tuberculosis, interferon gamma release assay was done which was negative. After this primary diagnosis of tubo-ovarian abscess was made.
A transabdominal USG guided aspiration of the fluid done and sent for geneXpert®, cell cytology, cell block and culture (bacterial/fungal/tubercular). GeneXpert® was negative for tuberculosis. The fluid cytology was negative for malignant cells and the cell block showed reactive mesothelial cells and neutrophils. The microbiological reports revealed a sterile bacterial culture. On fungal culture, fungal elements were grown that on Matrix assisted laser desorption ionization Time of flight – Mass spectrometry (MALDI-TOF MS) (Bruker Daltonics, Germany), showed it to be Curvularia lunata
She was started on oral standard Itraconazole 200mg once daily and was followed-up every week. During the second week of follow-up, an abdominal CECT was repeated that showed bilateral adnexal masses with dilated tubular structures with thickened enhancing walls, moderate fluid collection was still seen in the pelvis along with peritoneal thickening, and the lesion also showed calcifications and cystic components of various compositions suggesting diagnosis of a tubo ovarian abscess (Fig. 2). So, another therapeutic USG guided aspiration was done and 80 ml fluid was aspirated.
After 6 weeks of Itraconazole treatment, she was symptomatically improved Repeat MRI pelvis was done, that showed near total resolution of mass, bulk of bilateral ovaries was seen normally. Figure 2). Again, transabdominal ultrasound guided fluid aspiration was done from remaining cyst and sent for repeat fungal culture which was negative for any fungal elements. Itraconazole was stopped and she was kept on regular follow up. Two months later patient presented with a chest wall swelling and weight loss. A CT scan was done that showed miliary tuberculosis and cold abscess in the chest wall (Fig. 3). An aspiration was done and sent for geneXpert® that confirmed MDR tuberculosis, 3 months after the start of antitubercular treatment the cold abscess was regressed and the patient had reported 3 Kg of weight gain.