Isolated ovarian tuberculosis in a hemodialysis patient: An incidental pre-transplant discovery with diagnostic and management implications

Abstract

Female genital tuberculosis remains a rare extrapulmonary manifestation, particularly when presenting as isolated ovarian involvement mimicking malignancy. We report a case discovered incidentally during pre-transplant screening in an immunocompromised patient on hemodialysis. A 37-year-old woman with end-stage renal disease on hemodialysis for 5 years underwent routine pre-kidney transplant evaluation. Computed tomography revealed a multiloculated left adnexal mass (38 × 33 mm). She was asymptomatic without tuberculosis exposure history. Transvaginal ultrasound demonstrated a thin-septated avascular cystic lesion, while magnetic resonance imaging showed hyperintensity with fluid-fluid levels and no suspicious enhancement. Laboratory findings revealed mild anemia, elevated inflammatory markers, and mildly elevated cancer antigen 125 with normal human epididymis protein 4. Tuberculosis screening showed positive tuberculin skin test (12 mm) and positive interferon-gamma release assay, with normal chest radiography. Laparoscopic cystectomy was performed. Histopathology demonstrated epithelioid granulomas with Langhans giant cells, caseous necrosis, and rare acid-fast bacilli. Molecular testing and culture confirmed Mycobacterium tuberculosis without rifampin resistance. Anti-tuberculous therapy adapted to renal failure was initiated with favorable outcome. At 6-month follow-up, complete resolution was documented on pelvic ultrasound. At 12 months, with no recurrence and normalized inflammatory markers, the patient was successfully relisted for kidney transplantation. This case emphasizes the importance of maintaining high clinical suspicion for tuberculosis in immunocompromised patients presenting with adnexal masses, particularly those awaiting transplantation. Early microbiological diagnosis enabled conservative surgical management and timely treatment, preventing potentially life-threatening post-transplant reactivation.