Evaluating the clinical significances of serum HE4 with CA125 in peritoneal tuberculosis and epithelial ovarian cancer.

This study aimed to evaluate the clinical significances of human epididymis protein 4 (HE4) with cancer antigen 125 (CA125) in differential diagnosis between epithelial ovarian cancer (EOC) and peritoneal tuberculosis (PTB). We retrospectively reviewed data of 31 patients suspected preoperatively as having EOC but whose pathological results revealed PTB. The concentrations of serum HE4 and CA125 in PTB were significantly lower than that in EOC. The optimal cutoffs to differentiate EOC from PTB were HE4 > 151.4 pmol/l and CA125 > 563.5 U/ml, which means EOC may be considered if HE4 or CA125 was greater than the cutoff, otherwise, PTB should not be neglected. Furthermore, the specificity and accuracy for differentiating PTB form EOC could be improved when combination HE4 and CA125. Conclusively, the combination of HE4 and CA125 may be recommended as potential biomarkers in the preliminary differential diagnosis of PTB from EOC before the "golden standard" of pathologic diagnosis finally obtained.

Can D-dimer levels predict the treatment outcome in a patient with tuberculosis?

Tuberculous peritonitis is a leading cause of mortality and morbidity particularly in the developing world. Delay in initiation of treatment distinctively increases mortality. Treatment response to anti-tuberculosis drugs is usually observed by regression of symptoms and clearance of ascites. With initiation of treatment, laboratory values including CA-125 levels generally return to normal levels in 3 months. However, there is still no consensus about treatment response during the follow-up period. Serum D-dimer level is used as an inflammation marker in some cases. A case with Tuberculous peritonitis successfully monitorised by serum D-dimer levels is presented.

Clinical significance of serum CA-125 in Korean females with ascites.

PURPOSE: Mycobacterium tuberculosis is endemic in Korea. Because tuberculous peritonitis is characterized by ascites, abdominal pain, abdominal mass and elevation of serum CA-125, it can be confused with ovarian malignancies. The aim of this study was to evaluate the significance of serum CA-125 level in the differential diagnosis of tuberculous peritonitis and ovarian malignancy in a Mycobacterium tuberculosis-endemic area. MATERIALS AND METHODS: The medical records of patients diagnosed with tuberculous peritonitis (n=48) or epithelial ovarian malignancy (n=370) at Samsung Medical Center from January 2000 to October 2009 were retrospectively reviewed. RESULTS: Median serum CA-125 level in the epithelial ovarian cancer group was significantly higher than that in the tuberculous peritonitis group (p ≤ 0.01). Only one patient (2.1%) in the tuberculous peritonitis group had a serum CA-125 level over 2000 U/mL. However, 109 patients (29.5%) in the epithelial ovarian cancer group had a serum CA-125 level over 2000 U/mL. At the CA-125 ranges of 400 to 599 and 600 to 799, the proportions of those with tuberculous peritonitis were 24% and 21.9%, respectively. At a serum CA-125 level over 1000 U/mL, however, the proportion of tuberculous peritonitis was much lower (2.1%). CONCLUSION: Tuberculous peritonitis should be considered in the evaluation of female patients with ascites and high serum CA-125.

[Changes parameters of humoral immunity in abdominal tuberculosis].

We measured the levels of IL-1beta, IL-8, and TNF-alpha, as well as humoral immunity in blood serum of patients with abdominal tuberculosis before and after Koch's test. The content of TNF-alpha increased 2.5 times, the content of IL-8 decreased almost twice, and concentration of IL-1beta decreased three times compared to the controls. We found that Koch's test exacerbates pathogenic manifestations of chronic inflammation which shows changes in cytokine spectrum of blood and allows us to refine diagnosis of abdominal tuberculosis.

Adenosine deaminase activity in tuberculous peritonitis among patients with underlying liver cirrhosis.

AIM: To investigate the value of adenosine deaminase (ADA) for early detection of tuberculous peritonitis (TBP) among cirrhotic patients. METHODS: We retrospectively analyzed 22 patients with TBP from July 1990 to June 2010. Twenty-five cirrhotic patients with uninfected ascites were prospectively enrolled as the cirrhosis control group from July 2010 to June 2011. An additional group of 217 patients whose ascites ADA levels were checked in various clinical conditions were reviewed from July 2008 to June 2010 as the validation group. RESULTS: The mean ascites ADA value of cirrhotic patients with TBP (cirrhotic TBP group, n = 8) was not significantly different from that of non-cirrhotic patients (non-cirrhotic TBP group, n = 14; 58.1 ± 18.8 U/L vs. 70.6 ± 29.8 U/L, P = 0.29), but the mean ascites ADA value of the cirrhotic TBP group was significantly higher than that of the cirrhosis control group (58.1 ± 18.8 U/L vs. 7.0 ± 3.7 U/L, P < 0.001). ADA values were correlated with total protein values (r = 0.909, P < 0.001). Using 27 U/L as the cut-off value of ADA, the sensitivity and specificity were 100% and 93.3%, respectively, for detecting TBP in the validation group. CONCLUSION: Even with lower ADA activity in ascites among cirrhotic patients, ADA values were significantly elevated during TBP, indicating that ADA can still be a valuable diagnostic tool.

Comparison between peritoneal tuberculosis and primary peritoneal carcinoma: a 16-year, single-center experience.

BACKGROUND: Peritoneal tuberculosis and primary peritoneal carcinoma can both present as an abdominal mass and ascites with elevated serum CA125. The purpose of our study was to evaluate the clinical features of peritoneal tuberculosis, compare them with features of primary peritoneal carcinoma, and establish definitive diagnostic procedures. METHODS: We conducted a retrospective study in patients with peritoneal tuberculosis from January 1995 to October 2010 at Peking Union Medical College Hospital. During this time, the data of 38 patients with primary peritoneal carcinoma were reviewed. RESULTS: The median age was 34 years (range, 19 - 80 years). The most common symptoms were abdominal distension (16/30, 53.3%) and an abdominal mass (12/30, 40.0%). The serum CA125 level was elevated in 25 patients (83.3%). The median level of cancer antigen CA125 was 392.5 U/ml (range, 0.6 - 850.0 U/ml). Abdominal ultrasound revealed a pelvic mass in 25 patients and ascites in 20 patients. Diagnostic laparoscopy was performed in 15 patients (50.0%) and exploratory laparotomy was performed in 12 patients (40.0%), and 3 patients (10.0%) who underwent laparoscopy converted to laparotomy because of severe adhesions. The intraoperative findings were adhesions, multiple white tubercles, and ascites. Frozen tissue sections were obtained in 17 patients, and 14 of whom showed chronic granulomatous reactions. Final pathological examinations confirmed the diagnosis. CONCLUSIONS: Peritoneal tuberculosis should be considered as a differential diagnosis, especially for young women with an abdominal mass, ascites, and elevated serum CA125 levels. Laparoscopy is a useful diagnostic method for peritoneal tuberculosis, and intraoperative frozen sections are recommended when the diagnosis is in doubt.

A patient with tuberculous peritonitis with very high serum CA 125.

An 88-year-old woman presented with abdominal pain and distension. Serum cancer antigen 125 (CA 125) level was very high; however, abdominal CT reveals ascites without definite mass. Ascites analysis revealed a lymphocytic exudate with high adenosine deaminase enzyme level, negative stains for bacteria and negative PCR for Mycobacterium tuberculosis. Presumptive diagnosis for tuberculous peritonitis was made and antituberculous therapy resulted in the resolution of ascites and normalisation of CA 125.

Differentiation of tuberculous peritonitis from peritonitis carcinomatosa without surgical intervention.

BACKGROUND/AIM: Ascites of tuberculous peritonitis (TBP) is an exudative type and may well be misdiagnosed as carcinomatous peritonitis, especially in the elderly. The aim of this study was to identify independent predictors that can differentiate TBP from peritonitis carcinomatosa without surgical intervention. PATIENTS AND METHODS: This prospective cohort study was performed on 75 subjects in the following groups: TBP (n=27) (TBP group), ovarian cancer complicated with ascites (n=24) (Ov Ca group), and gastric cancer complicated with ascites (n=24) (Ga Ca group). The frequency of clinical symptoms, laboratory parameters, and serum tumor markers levels were compared. RESULTS: In univariate analysis; fever, night sweats, and abdominal pain were significantly more frequent in the TBP group compared to those in the Ov Ca group (P < 0.001, P < 0.001, and P = 0.035, respectively) and the Ga Ca group (P < 0.001, P < 0.001, and P = 0.015, respectively). Serum CA 19-9 and carcino embryonic antigen (CEA) levels were significantly lower in the TBP and Ov Ca group compared to the Ga Ca group (P < 0.001 and P < 0.001, respectively). Elevated serum CA 125 level was found in all patients with TBP and Ov Ca and in 86.6% of patients with Ga Ca. In the multivariate analysis, presence of fever (P < 0.001), night sweats (P < 0.001), age under 40 years (P = 0.008), and normal serum CA 19-9 level (P = 0.044) were independent predictor of diagnosis of TBP. CONCLUSION: The presence of fever, elevated serum CA 125 level, normal serum CA 19-9, and CEA associated with lymphocyte predominant benign ascites may establish the diagnosis of TBP.

Raised CA125 serum level in tubercular peritonitis.

A 24-year old woman was admitted with a history of fever and pelvic pain. ESR and CA125 serum level were high and PPD test was negative. Ultra sound and CT evaluation detected free fluid in abdominopelvic cavity. Laparotomy showed fibrinous strands adhering to and fibrotic sac surrounding the components of abdominal cavity. Opening the sac, grey miliary nodules were spotted and pathologic examination revealed multiple granulomatous lesions. Diagnosed with TBP, patient underwent specific antibiotic therapy and her condition improved significantly following treatment. As laboratory findings and image analysis may be misleading in diagnosis of TBP, diagnostic approach of laparotomy and subsequent pathologic examination is of vital value--particularly in premenopausal female patients to preserve fertility.

A case of tuberculous peritonitis in a hemodialysis patient with high serum soluble interleukin-2 receptor and CA-125 levels.

A hemodialysis patient with tuberculous peritonitis with hypercalcemia and high serum soluble interleukin-2 receptor (sIL-2R) and CA-125 levels is reported. An 82-year-old woman who had been on hemodialysis therapy for 6 years was admitted to our hospital for evaluation and treatment of hypercalcemia. Laboratory examination and radiologic studies revealed markedly increased serum sIL-2R and CA-125 levels and exudative ascites, with high levels of adenosine deaminase (ADA) and CA-125, which was suggestive of malignancy or tuberculosis. She was finally diagnosed as having tuberculous peritonitis based on positivity for Mycobacterium tuberculosis in ascitic fluid. The ascites subsided with normalization of hypercalcemia and a marked decrease in serum sIL-2R and CA-125 levels in response to anti-tuberculosis treatment. This case indicates that serum sIL-2R and CA-125 levels can rise to levels suggestive of malignancy in tuberculous peritonitis, and that they can be used to monitor the response to anti-tuberculosis treatment.

Diagnostic dilemma of abdominopelvic tuberculosis:a series of 20 cases.

OBJECTIVE: To establish more effective diagnostic procedures to identify the characteristic features of abdominopelvic tuberculosis (APTB) mimicking advanced ovarian cancer. METHODS: A retrospective review of 20 cases of APTB mimicking advanced ovarian cancer was undertaken. RESULTS: The mean age of the patients was 28.9 ± 10.8 years. The main clinical manifestations were abdominal pain (45%) and distention (45%). CA125 level was elevated in 18 cases (90.0%). Pelvic mass in 18 patients (90.0%) and ascites in 12 patients (60.0%) were detected by using abdominal US. The bacteriologic cultures and cytological studies were all negative (10 cases, 100%). Laparotomy (17 cases) and laparoscopic evaluation (1 case) was performed with the presumptive diagnosis of advanced ovarian cancer except for 2 patients treated with diagnostic anti-TB chemotherapy. The common intra-operative findings were miliary nodules (14 cases, 77.8%) and widespread adhesion (10 cases, 55.6%). Intra-operative frozen section was obtained in 10 cases, and the typical tuberculosis tubercles were detected in all cases. CONCLUSION: APTB should be considered in all cases with pelvic mass, ascites and high levels of CA125, although clinical features and laboratory results specifically indicate neither ovarian malignancy nor APTB. Diagnostic laparotomy is a direct and safe method. To avoid extended surgery, the cases with APTB can be diagnosed through intra-operative frozen section in conjunction with clinical features.

Peritoneal tuberculosis in premenopausal patients with elevated serum CA 125.

INTRODUCTION: Peritoneal tuberculosis predominantly involves the omentum, intestinal tract, liver, spleen, and genitourinary tract and occurs in 1-4% of patients with pulmonary tuberculosis. Peritoneal tuberculosis may mimic a pelvic mass in imaging studies and also may increase CA-125 levels. Peritoneal tuberculosis may also produce massive ascites, and intraperitoneal gross appearance might be similar to the peritoneal carcinomatosis. Therefore, peritoneal tuberculosis is often confused with advanced-stage epithelial carcinoma because of similar clinical, radiologic, and laboratory findings and later intraoperative findings. MATERIALS AND METHODS: The pathology records between January 2000 and August 2008 were retrospectively reviewed at 19 Mayis University Hospital. Twenty-two patients were found to have peritoneal caseating necrosis. A total of 13 out of 22 patients were found to have high CA 125 level. RESULTS: Among these 13 patients, 8 patients received/are receiving anti-tuberculous therapy after they were incidentally diagnosed with peritoneal tuberculosis. CONCLUSION: Increased CA 125 levels should be evaluated carefully prior to aggressive surgical approach, especially in premenopausal women and frozen section evaluation should be done before extensive surgical procedure if there is any suspicion.

[Ascites with high protein concentration 2 months after C-section delivery: diagnosis using adenosine deaminase analysis combined with iconography]. / Ascite riche en protides survenant deux mois après un accouchement par césarienne: diagnostic par association du dosage de l'adénosine-désaminase et de l'imagerie.

We report the case of a 38-year-old woman, born and raised in Congo, in France for 7 years, who developed ascites 2 months after delivery by C-section. Thrombopenia at 95,000 elements per millimeter cube was diagnosed during her pregnancy and her obstetrician initiated a treatment with corticosteroids. Analysis of the ascitic fluid showed a high concentration of proteins (55.7 g/l), with 2000 elements, 80% of which were lymphocytes, and very high levels of adenosine deaminase. Thoracoabdominal tomodensitometry revealed ascites, a multinodular spleen, and hyperemia of the peritoneum; but the liver and the lungs were normal and no adenoma was identified. Laparoscopy was not performed and the suspected diagnosis of peritoneal tuberculosis was confirmed by only one culture of ascitic fluid.

Tuberculous peritonitis in cirrhotic patients: comparison of spontaneous bacterial peritonitis caused by Escherichia coli with tuberculous peritonitis.

The aim of this study was to compare the characteristics of tuberculous peritonitis (TP) and spontaneous bacterial peritonitis (SBP) in cirrhotic patients. In a retrospective review of the medical records of a single tertiary hospital between 1988 and 2006, 15 patients met the diagnostic criteria TP and liver cirrhosis. For comparison, we randomly selected 3 cirrhotic patients with SBP caused by Escherichia coli for each cirrhotic patient with TP. Compared to SBP, TP in cirrhotic patients was more frequently associated with extra-peritoneal tuberculosis (TP vs SBP: 53.3% vs 0%), an insidious onset (> or =2 weeks; 60% vs 2.2%), and Child-Pugh classification class B at onset (80% vs 8.9%) (p<0.05). Compared to SBP, TP was associated with lower white blood cell count in ascites (TP vs SBP: 2.0+/-2.2 x 10(3)/mm(3) vs 7.2+/-7.5 x 10(3)/mm(3)), a higher proportion of mononuclear leukocytes (lymphocytes and monocytes) in ascites (88.9+/-9.5% vs 16.6+/-15.3%), higher protein concentration in ascites (3.1+/-1.7 g/dl vs 1.2+/-0.3 g/dl), and higher adenosine deaminase activity in ascites (62.3+/-31.8 U/l vs 6.9+/-3.1 U/l) (p<0.05). TP should be suspected in cirrhotic patients with relevant clinical manifestations and characteristics of ascites.

Pelvic-peritoneal tuberculosis simulating peritoneal carcinomatosis: high clinical suspicion and a minimally invasive procedure.

Peritoneal tuberculosis (TB) is still a major health problem in developing countries. We describe a 26-year-old woman with peritoneal TB presenting with lower abdominal pain and distention, weight loss, and night sweats. There are no pathognomonic clinical, laboratory, or radiologic findings for peritoneal TB. Therefore, it can be easily confused with peritoneal carcinomatosis and advanced ovarian carcinoma. Adenosine deaminase activity in ascitic fluid combined with a high clinic suspicion is an effective and minimally invasive procedure for the differential diagnosis of pelvic-peritoneal TB simulating peritoneal carcinomatosis, and may obviate the need for unnecessary extensive surgery and rapidly initiate appropriate therapy.

Peritoneal tuberculosis with elevated serum Ca-125 level mimicking advanced stage ovarian cancer: a case report.

BACKGROUND: Tuberculosis is still a common problem in immigrant population with peritoneal tuberculosis as the most common presentation of extrapulmonary disease. CASE: A 36-year-old woman presented with abdominal distention, night sweats and weight loss. Physical examination and radiologic studies revealed ascites, omental caking and bilateral enlarged ovaries with an elevated serum Ca-125 of 353 U/mL. Acid-fast stain and culture were negative for Mycobacterium tuberculosis. Diagnostic laparoscopy and biopsy revealed multiple granulomas with epithelioid cells and caseification necrosis confirming tuberculosis. Treatment with anti-tuberculin drugs resulted in resolution of symptoms with a reduction in Ca-125 to normal. CONCLUSION: Laparoscopic biopsy with frozen section evaluation would spare patients with peritoneal tuberculosis from unnecessary extensive surgery. Serum Ca-125 level may be useful in monitoring treatment response.