CA 125 is a tumor marker best used for the diagnosis and follow up of patients with ovarian cancer. However CA 125 is a non specific marker and is elevated in other malignant and non malignant states. We report a patient with ascites due to peritoneal tuberculosis in whom raised levels of CA 125 prompted an erroneous diagnosis of metastatic ovarian carcinoma.
A 33 year old woman from Bangladesh presented with two-weeks of abdominal pain, abdominal distension, fever, 15-LB weight loss and generalized weakness. Patient had temperature of 100.2 F, abdominal distension with ascites without hepatospleenomegaly. Blood hemoglobin was 11.6 gm/dl, ESR 45, WBC count of 4.8, amylase 94. Liver function test and blood electrolytes were normal. Ascitic fluid showed glucose 61, protein 5.4, LDH 470, RBC 15000, WBC 230 with lymphocytes 60%, monocytes 18%, and neutrophil 22%. Ascitic fluid was negative for AFB and cytology was negative for malignancy. Chest x-ray was normal. PPD reveled 20 mm induration. Serum CA-125 level was raised at 592.13. Transvaginal ultrasound showed right ovarian cyst. CT scan of abdomen and pelvis showed thickening of stomach wall, cystic lesion in head of pancreas and multiple nodules on the peritoneum suggestive of metastasis. Gastroduodenoscopy was normal. Patient underwent exploratory laprotomy to confirm the diagnosis and for possible debulking of metastatic ovarian cancer. Laprotomy showed multiple nodular lesions on the peritoneal surface extending from under surface of diaphragm to ovary including omentum and small bowel. No intraabdominal mass was seen. Biopsy of nodular lesion showed caseating granuloma and AFB. The patient was started on isoniazid, rifampin, ethambutol and pyrizinamide with improvement. Repeat CA-125 done upon completion of therapy was normal.
CA-125 is elevated in many malignant and non-malignant conditions including tuberculosis. CA-125 is expressed by coelemic epithelium cell that lines serosal surface and by bronchial epithelial cells. On activation by inflammation or tumor, these cells secret CA-125. As a result of this CA-125 is elevated in active pulmonary and extra pulmonary tuberculosis and normalizes after antituberculous therapy. Serum CA 125 level is elevated in malignant conditions such as cancer of ovary, endometrium, cervix, breast, colon, lung and pancreas. Non malignant conditions include cirrhosis of liver, CHF, DM, pericarditis, sarcoidosis, tuberculosis, endometriosis, menstruation, pregnancy and pelvic inflammatory disease.
Peritoneal tuberculosis is uncommon in the developed world. The presenting signs, symptoms, imaging studies and raised CA-125 level in peritoneal tuberculosis may resemble that of ovarian cancer leading to erroneous diagnosis. Only a high index of suspicious and knowledge that CA 125 is raised in tuberculosis will prevent erroneous diagnosis. Peritoneal tuberculosis should be considered in patients with ascites and peritoneal nodules especially in patients coming from areas where tuberculosis is endemic.
D.P. Malli, None.