Transcript Clinical Pathological Conference

Clinical Pathological
Conference
May 11, 2007
CHIEF COMPLAINT:
51 year old female with
abdominal bloating, twenty pound
weight loss, and fatigue
for 2 months.
DEFENDING DIAGNOSES
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Ovarian Carcinoma (9): David Jacobs
Krukenberg Tumor (1): Daniel Shen
Pelvic Tuberculosis (3): Vanessa Starr
Pancreatic adenocarcinoma (1): Jeremy Fenton
• Other Diagnoses:
Meig’s syndrome
Antiphospholipid syndrome
Pseudomyxoma Peritonei
RADIOLOGY
Dr. Michael Macari
Associate Professor,
Department of Radiology
Pelvic Ultrasound
Pelvic Ultrasound
FACULTY DISCUSSANT
Dr. David Chong
Associate Program Director
Assistant Professor of Medicine,
Pulmonary Disease
PATHOLOGY
Dr. Jian-jun Wei
Assistant Professor,
Department of Pathology
Right Ovary
Right Ovary
Right Ovary
Right Peritoneum
Right Peritoneum
Right Peritoneum
Right Iliac Lymph Node
Right Iliac Lymph Node
Right Iliac Lymph Node
FINAL DIAGNOSIS
• Pathologic Diagnosis: Non-caseating
Granulomas
• Presumed Clinical Diagnosis:
Tuberculosis of the Female Genital Tract
Hospital Course and Follow-up
• The patient had a GI and GYN
workup for malignancy.
• Her EGD showed:
– Normal esophagus. Atrophic mucosa in
antrum. Normal dudodenum.
– Negative Helicobacter pylori.
– Pathology: chronic mildly active gastritis
with extensive metaplasia.
Hospital course and Follow-up
• The patient had an exploratory laparotomy
– Evidence of miliary disease
– Bilateral oopherectomy and hysterectomy
– Pathology: Non-caseating granulomas. (AFB -)
• Tuberculosis versus Sarcoidosis
• 6 month course of IRPE 6 given for
presumed tuberculosis of the female
genital tract
Epidemiology of Tuberculosis of the
Genital Tract
• Common in underdeveloped nations
• Most affected woman are in the reproductive
age-group
• In Guyana*,
– 900 new cases of active tb per year
– estimated annual rate of infection is 3.2%
– estimated 14% of the population is infected
*World TB report 2005
Pathogenesis of Miliary Tuberculosis
Bacilli in the air
(droplet nuclei) inhaled
Replication in dependant
lobe: primary focus
Early lymphohematogenous
spread
Latent Foci
TB lymphadentis,
Miliary Tuberculosis
Clinical Presentation and laboratory data of
Tuberculosis of the Genital Tract
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Abdominal pain
Pelvic pain
Ascites
Diarrhea
Infertility
Weight loss
• Amenorrhea or
irregular menses
• Fever
• Anemia
• Elevated CA-125
Making the Diagnosis of
Tuberculosis of the Genital Tract
• Laparoscopically directed biopsy
• Premenstrual endometrial tissue biopsy
• Histologic and PCR tests of peritoneal fluid,
menstrual blood culture
• Exploratory laparotomy
Radiographic Features of
Tuberculosis
Treatment of Tuberculosis of the
Genital Tract
• Similar to treatment for TB at
extrapulmonary sites.
• A 6-mo regimen
– 2 months of isoniazid, rifampin, and
pyrazinamide
– 4 months of isoniazid and rifampin
– Ethambutol should be used until the results of
drug susceptibility studies are available, unless
there is little possibility of drug resistance
Thank you
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Medical Students
Dr. Macari
Dr. Chong
Dr. Wei
Dr. Grieco
Dr. Blaser