Diagnostic challenges of peritoneal tuberculosis in women presenting to gynaecology: a retrospective descriptive study in a tuberculosis-endemic region

Background: Peritoneal tuberculosis (PTB) is a rare form of extrapulmonary tuberculosis that poses significant diagnostic challenges in Gynaecological practice due to its resemblance to ovarian malignancies. In regions endemic for tuberculosis, timely diagnosis is crucial to avoid misdiagnosis and unnecessary surgical intervention. Objective: To describe the clinical presentation, diagnostic pathways, and treatment outcomes of four consecutive cases of PTB encountered in a Gynaecology unit at a teaching hospital in Sri Lanka between 2019 and 2023. Methods: This retrospective descriptive study reviewed medical records of a cohort of four histologically or microbiologically confirmed cases of PTB. Data collected included clinical symptoms, imaging findings, laboratory parameters (including CA-125 and ESR), Mantoux test results, peritoneal fluid analysis, laparoscopy findings, histopathology, TB PCR, culture results, and treatment response. Results: Patients ranged in age from 18 to 51 years and presented with abdominal distension, subfertility, postpartum fever, or chronic pelvic pain. All had a positive Mantoux test, and two showed elevated CA-125 levels suggestive of malignancy. Peritoneal fluid analysis supported the diagnosis in three cases, although AFB smear and culture were negative. Laparoscopy revealed miliary tubercles in all cases and facilitated biopsy, which confirmed caseating granulomatous inflammation. TB PCR and tissue cultures confirmed Mycobacterium tuberculosis in every case. All patients responded excellently to standard anti-tuberculosis therapy. Conclusion: PTB, although uncommon in Gynaecology, should be considered in women presenting with ascites, elevated CA-125, or infertility, especially in endemic regions. Laparoscopy with histopathological sampling remains essential for definitive diagnosis, enabling timely treatment and preventing unnecessary surgical procedures. Standard ATT dosing ensures excellent outcomes while avoiding radical surgery.