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Sir,

I was most interested to read the case report of Sindha et al. (Vol 107, January 2000)1 which highlighted the fact that pelvic tuberculosis is certainly not obsolete in Western society. However I must question their conclusion that medical treatment, on its own, is not an effective treatment in advanced cases of this disease.

I was part of the team involved in the care of a similar case in 19962, when a 32 year old woman was admitted with a 2-week history of weight loss, lethargy, abdominal swelling and an unproductive cough. A pelvic ultrasound scan revealed marked ascites and a 4.5 cm left adenexal mass, with a CA125 level of 417 KU/L (normal < 30). Mantoux testing and culture of the ascitic fluid were both negative but a chest x-ray showed bilateral pleural effusions. A laparotomy was undertaken and 3 L of ascitic fluid were drained. An omental cake was found to be adherent to the anterior abdominal wall and numerous miliary seedlings were found throughout the peritoneal cavity. Advanced carcinoma of the ovary was suspected and radical surgery was abandoned. A left salpingo-oophorectomy and omental biopsy were performed.

Cytology showed no malignant cells and histology revealed multiple caseating granulomata, consistent with a diagnosis of tuberculosis. The patient was started on triple therapy of isoniazid, rifampicin and pyrizinamide and within a few days noted a marked improvement in her symptoms. Nine months later after completion of her treatment, she had regained 10 kg in weight, her CA125 had returned to normal and her symptoms had resolved completely.

Although the reason for avoiding radical surgery in this case was due to the abandonment of the procedure in such advanced supposed carcinoma of the ovary, this case shows that medical treatment alone may be an effective treatment in pelvic tuberculosis. Total abdominal hysterectomy and bilateral salpingo-oophorectomy is not always necessary.

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