DOI: 10.1148/rg.246045016
RadioGraphics 2004;24:1575-1589
© RSNA, 2004
Unusual Causes of Tubo-ovarian Abscess: CT and MR Imaging Findings1
Sun Ho Kim, MD,
Seung Hyup Kim, MD,
Dal Mo Yang, MD and
Kyeong A. Kim, MD
1 From the Department of Radiology, Seoul National University College of Medicine, Seoul, Korea (S.H.K., S.H.K.); the Department of Radiology, Gachon Medical School, Gil Medical Center, Incheon, Korea (D.M.Y.); and the Department of Radiology, Korea University Guro Hospital, Seoul (K.A.K.). Presented as an education exhibit at the 2003 RSNA scientific assembly. Received February 11, 2004; revision requested March 19 and received April 23; accepted April 26. All authors have no financial relationships to disclose. Address correspondence to Seung Hyup Kim, Department of Radiology, Seoul National University Hospital, 28 Yongon-Dong, Chongno-Gu, Seoul 110–744, Korea (e-mail: kimsh@radcom.snu.ac.kr).
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Abstract
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Actinomycosis, tuberculosis, and xanthogranulomatous inflammation are rare but specific causes of tubo-ovarian abscess (TOA). TOAs with these causes are frequently misdiagnosed as ovarian malignancies due to their unusual appearances at computed tomography (CT) and magnetic resonance (MR) imaging. Tubo-ovarian actinomycosis frequently has a predominantly solid appearance. A linear, solid, well-enhancing lesion extending directly from the mass is a characteristic CT and MR imaging finding. Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis. Tuberculous TOAs usually mimic peritoneal carcinomatosis from ovarian cancers. The granulomatous and fibrotic nature of this infection may be reflected in the CT and MR imaging appearances, which can help in differentiation. TOAs from xanthogranulomatous inflammation demonstrate more nonspecific imaging findings than actinomycotic or tuberculous TOAs, although multiple xanthogranulomas in the mass may be seen on MR images. Knowledge of these characteristics can help one make the correct diagnosis and treat the patients appropriately.
© RSNA, 2004
Index Terms: Actinomycosis, 85.2044 • Fallopian tubes, abscess, 853.2174 • Ovary, abnormalities, 852.2174 • Ovary, neoplasms, 852.30 • Tuberculosis, genitourinary, 85.231
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LEARNING OBJECTIVES FOR TEST 2
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After reading this article and taking the test, the reader will be able to:
- List the unusual causes of TOAs, which frequently mimic ovarian malignancies.
- Describe the CT and MR imaging findings of TOAs with unusual causes.
- Discuss the CT and MR imaging features that can help differentiate such TOAs from typical TOAs or ovarian malignancies.
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Introduction
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Tubo-ovarian abscess (TOA) is a late complication of pelvic inflammatory disease (PID) and involves a frank abscess or an inflammatory mass resulting from breakdown of the normal structure of fallopian tubes and ovaries by inflammation. It has been reported that TOA occurs in about one-third of patients hospitalized for PID. TOA usually occurs in young women but can occur rarely in postmenopausal patients. Use of an intrauterine device (IUD) is considered to be associated with an increased prevalence of TOA (1,2).
The clinical features of TOA and uncomplicated PID are similar, and differentiation is usually achieved with sonography. The typical sonographic finding of a TOA is a mass in the adnexal region or cul-de-sac with an adjacent fluid collection. The masses may be solid, cystic, or complex. Indistinct uterine margins and loss of midline endometrial echoes may be observed as ancillary findings (3). These findings are nonspecific in many cases, and a diagnosis of TOA is difficult by means of sonography alone without clinical information about inflammatory symptoms or signs. However, about 20% of patients with TOA may be afebrile or have a normal leukocyte count (2). Furthermore, the symptoms can be vague or even absent in the chronic stage. In these cases, the primary concern is differentiation from ovarian malignancies, and computed tomography (CT) or magnetic resonance (MR) imaging is required.
Many TOAs are treated with surgical resection, although mild ones could be managed medically. Specific organisms or causes are seldom identified. However, some unusual forms of infection show their characteristic features at pathologic examination, and the specific causes may be revealed. TOAs from actinomycosis, tuberculosis, and xanthogranulomatous inflammation represent such cases.
If actinomycosis or tuberculosis were strongly suspected at imaging, aspiration or biopsy may allow confirmation of the diagnosis and these cases might be managed with medical treatment (penicillin or antituberculous drug therapy). More important is the fact that these TOAs frequently mimic ovarian malignancies radiologically and clinically (4,5). Therefore, knowing the imaging findings of these infections is very important in the proper management of the cases.
The CT and MR imaging findings of these unusual TOAs overlap with those of other usual TOAs in many aspects. Therefore, we first briefly review the CT and MR imaging findings of usual TOAs, then describe the CT and MR imaging features of these unusual causes of TOAs.
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Usual Causes of TOA
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TOA results from ascending cervical or vaginal infection. Cultures from a TOA usually reveal a polymicrobial infection with a preponderance of anaerobes. The predominant organisms are Escherichia coli, Bacteroides fragilis, other Bacteroides species, aerobic Streptococcus, Peptococcus, and Peptostreptococcus (2).
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Imaging Findings of Typical TOAs
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Sonographic findings were mentioned in the introduction. The most common CT finding is a pelvic mass with uniform, thick walls and internal septations (Fig 1a). Anterior displacement of thickened mesosalpinx is also a common finding and indicates that the mass is of adnexal origin (Fig 1b). Fluid-filled tubular lesions with enhancing, thick walls are findings of pyosalpinx and are frequently seen adjacent to or in a portion of TOAs (Fig 1c). Thickening of the uterosacral ligament is visible when the inflammation extends posteriorly (Fig 1d) (3,6). Internal gas bubbles, strong indicators of TOA when present, are rarely found (1,3). The rectosigmoid colon and ureter are the most common organs that can be involved by TOA (6,7).
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Figure 1a. Typical TOAs. (a) Contrast-enhanced CT scan of a 40-year-old woman shows bilateral cystic masses (arrows) in the adnexal regions. The masses have thick, enhancing walls and septations. The thickness of the wall and the septa is generally uniform. (b) Contrast-enhanced CT scan of a 43-year-old woman shows a complex, solid and cystic mass (white arrows) in the right adnexal region. Note the thickened mesosalpinx with anterior displacement (black arrows). A cystic lesion (arrowheads) posterior to the uterus is part of another TOA in the left adnexa. (c) Contrast-enhanced CT scan of a 41-year-old woman shows a cystic mass (white arrows) in the right adnexal region. The mass is composed of multiple tubular lesions (black arrows) with thick, enhancing walls, findings suggestive of pyosalpinx. (d) CT scan obtained at the level of the lower pelvis (same patient as in c) shows bilateral thickening of the uterosacral ligaments (arrows).
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Figure 1b. Typical TOAs. (a) Contrast-enhanced CT scan of a 40-year-old woman shows bilateral cystic masses (arrows) in the adnexal regions. The masses have thick, enhancing walls and septations. The thickness of the wall and the septa is generally uniform. (b) Contrast-enhanced CT scan of a 43-year-old woman shows a complex, solid and cystic mass (white arrows) in the right adnexal region. Note the thickened mesosalpinx with anterior displacement (black arrows). A cystic lesion (arrowheads) posterior to the uterus is part of another TOA in the left adnexa. (c) Contrast-enhanced CT scan of a 41-year-old woman shows a cystic mass (white arrows) in the right adnexal region. The mass is composed of multiple tubular lesions (black arrows) with thick, enhancing walls, findings suggestive of pyosalpinx. (d) CT scan obtained at the level of the lower pelvis (same patient as in c) shows bilateral thickening of the uterosacral ligaments (arrows).
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Figure 1c. Typical TOAs. (a) Contrast-enhanced CT scan of a 40-year-old woman shows bilateral cystic masses (arrows) in the adnexal regions. The masses have thick, enhancing walls and septations. The thickness of the wall and the septa is generally uniform. (b) Contrast-enhanced CT scan of a 43-year-old woman shows a complex, solid and cystic mass (white arrows) in the right adnexal region. Note the thickened mesosalpinx with anterior displacement (black arrows). A cystic lesion (arrowheads) posterior to the uterus is part of another TOA in the left adnexa. (c) Contrast-enhanced CT scan of a 41-year-old woman shows a cystic mass (white arrows) in the right adnexal region. The mass is composed of multiple tubular lesions (black arrows) with thick, enhancing walls, findings suggestive of pyosalpinx. (d) CT scan obtained at the level of the lower pelvis (same patient as in c) shows bilateral thickening of the uterosacral ligaments (arrows).
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Figure 1d. Typical TOAs. (a) Contrast-enhanced CT scan of a 40-year-old woman shows bilateral cystic masses (arrows) in the adnexal regions. The masses have thick, enhancing walls and septations. The thickness of the wall and the septa is generally uniform. (b) Contrast-enhanced CT scan of a 43-year-old woman shows a complex, solid and cystic mass (white arrows) in the right adnexal region. Note the thickened mesosalpinx with anterior displacement (black arrows). A cystic lesion (arrowheads) posterior to the uterus is part of another TOA in the left adnexa. (c) Contrast-enhanced CT scan of a 41-year-old woman shows a cystic mass (white arrows) in the right adnexal region. The mass is composed of multiple tubular lesions (black arrows) with thick, enhancing walls, findings suggestive of pyosalpinx. (d) CT scan obtained at the level of the lower pelvis (same patient as in c) shows bilateral thickening of the uterosacral ligaments (arrows).
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At MR imaging, TOA usually appears as a pelvic mass with low signal intensity on T1-weighted images and heterogeneous high signal intensity on T2-weighted images (Fig 2) (2,8). The signal intensity of the content of the abscess can vary depending on its viscosity or protein concentration. A thin rim of high signal intensity in the innermost portion of the abscess on T1-weighted images is frequently found and represents a layer of granulation tissue with microscopic hemorrhage (Fig 2a). Shading in the peripheral portion of the abscess cavity on T2-weighted images has also been reported as a common finding. Meshlike strands in the pelvic fat planes due to dense pelvic adhesions or fibrosis are almost always found and are hypointense on T2-weighted images and well-enhancing (Fig 2b, 2c) (2).
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Figure 2a. Typical TOA in a 33-year-old woman. (a) Axial T1-weighted MR image shows a left adnexal mass (solid arrows) with high signal intensity of the inner wall (arrowheads). Some hemorrhage is also noted (open arrow). (b) Axial T2-weighted MR image shows that the mass (solid arrows) is septate and cystic with a thick wall. The contents have high signal intensity, which is lower than that of a pure cyst. Meshlike strands in the pelvic fat planes (open arrows) are noted. (c) Axial contrast-enhanced T1-weighted MR image shows good enhancement of the wall and septa of the mass (white arrows). The meshlike strands in the pelvic fat planes (black arrows) also enhance well.
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Figure 2b. Typical TOA in a 33-year-old woman. (a) Axial T1-weighted MR image shows a left adnexal mass (solid arrows) with high signal intensity of the inner wall (arrowheads). Some hemorrhage is also noted (open arrow). (b) Axial T2-weighted MR image shows that the mass (solid arrows) is septate and cystic with a thick wall. The contents have high signal intensity, which is lower than that of a pure cyst. Meshlike strands in the pelvic fat planes (open arrows) are noted. (c) Axial contrast-enhanced T1-weighted MR image shows good enhancement of the wall and septa of the mass (white arrows). The meshlike strands in the pelvic fat planes (black arrows) also enhance well.
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Figure 2c. Typical TOA in a 33-year-old woman. (a) Axial T1-weighted MR image shows a left adnexal mass (solid arrows) with high signal intensity of the inner wall (arrowheads). Some hemorrhage is also noted (open arrow). (b) Axial T2-weighted MR image shows that the mass (solid arrows) is septate and cystic with a thick wall. The contents have high signal intensity, which is lower than that of a pure cyst. Meshlike strands in the pelvic fat planes (open arrows) are noted. (c) Axial contrast-enhanced T1-weighted MR image shows good enhancement of the wall and septa of the mass (white arrows). The meshlike strands in the pelvic fat planes (black arrows) also enhance well.
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These CT and MR imaging findings are not specific, and differential diagnosis from abscesses with nongynecologic origins, benign or malignant ovarian tumors, uterine myomas, and endometriotic cysts is needed, especially when clinical signs and symptoms are vague (1,2).
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Actinomycosis
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Actinomycosis is a chronic suppurative infection by Actinomyces israelii. Formation of multiple abscesses and abundant granulation tissue is characteristic, and fibrosis is also common. It has an invasive nature, showing spread by direct extension across the tissue planes with the formation of multiple abscesses, tracts, and sinuses. Proteolytic enzymes make this invasive pattern of spread possible. The presence of sulfur granules at pathologic examination is important in diagnosing this infection, as well as multiple Gram-positive branching hyphae (9–11).
The cervicofacial region is the site that is most frequently affected (63%), followed by the abdomen (22%) and thorax (15%). Pelvic actinomycosis is considered to be highly associated with ascending infection from the female genital tract, and the use of intrauterine contraceptive devices is thought to increase the prevalence (11,12). This infection is susceptible to high doses of penicillin.
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Imaging Findings of TOAs from Actinomycosis
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Common sonographic findings are solid adnexal masses with some cystic portions, which are nonspecific and difficult to differentiate from those of malignant ovarian tumors. At CT, tubo-ovarian actinomycosis usually appears as a predominantly solid (Figs 3, 4, 5a) or a solid and cystic mass in the adnexal region. It may be well or poorly defined, according to the acute or chronic stage of the infection (Figs 3, 4). Contrast enhancement is very prominent in the solid portion (13). Small, rim-enhancing lesions are sometimes found in the solid portion of the mass (Figs 3a, 5a). These lesions are thought to be small abscesses, although exact pathologic correlation has not been demonstrated. Thick, linear, and well-enhancing lesions extending directly from the mass into the adjacent tissue planes (Fig 3b, 3c), which reflects the invasive nature of actinomycosis, are frequently found and may be characteristic findings. Sometimes, these inflammatory extensions form perirectal masses or masses in the cul-de-sac, mimicking seeding masses from ovarian malignancies (Fig 3c). IUDs are found in many cases (Fig 3c), but they cannot be strong indicators of actinomycosis because IUDs are also commonly found with other causes of TOAs and the absence of an IUD on CT scans does not mean absence of a history of IUD use.
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Figure 3a. Tubo-ovarian actinomycosis in a 44-year-old woman. The TOA has a predominantly solid appearance. (a) Contrast-enhanced CT scan shows a round, solid mass (arrows) in the right adnexal region. Multiple small, rim-enhancing lesions (arrowheads) are seen inside the mass. (b) Contrast-enhanced CT scan obtained caudad to a shows a well-enhancing solid lesion (arrows) extending posteriorly from the mass. (c) Contrast-enhanced CT scan obtained caudad to b shows an enhancing perirectal mass (arrows), which is formed by the lesion extending from the adnexal mass. An IUD is noted (arrowhead). (d) Image from a barium study of the rectosigmoid shows segmental narrowing of the distal sigmoid colon with a serrated border (arrows), an appearance indicative of invasion by the perirectal mass.
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Figure 3b. Tubo-ovarian actinomycosis in a 44-year-old woman. The TOA has a predominantly solid appearance. (a) Contrast-enhanced CT scan shows a round, solid mass (arrows) in the right adnexal region. Multiple small, rim-enhancing lesions (arrowheads) are seen inside the mass. (b) Contrast-enhanced CT scan obtained caudad to a shows a well-enhancing solid lesion (arrows) extending posteriorly from the mass. (c) Contrast-enhanced CT scan obtained caudad to b shows an enhancing perirectal mass (arrows), which is formed by the lesion extending from the adnexal mass. An IUD is noted (arrowhead). (d) Image from a barium study of the rectosigmoid shows segmental narrowing of the distal sigmoid colon with a serrated border (arrows), an appearance indicative of invasion by the perirectal mass.
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Figure 3c. Tubo-ovarian actinomycosis in a 44-year-old woman. The TOA has a predominantly solid appearance. (a) Contrast-enhanced CT scan shows a round, solid mass (arrows) in the right adnexal region. Multiple small, rim-enhancing lesions (arrowheads) are seen inside the mass. (b) Contrast-enhanced CT scan obtained caudad to a shows a well-enhancing solid lesion (arrows) extending posteriorly from the mass. (c) Contrast-enhanced CT scan obtained caudad to b shows an enhancing perirectal mass (arrows), which is formed by the lesion extending from the adnexal mass. An IUD is noted (arrowhead). (d) Image from a barium study of the rectosigmoid shows segmental narrowing of the distal sigmoid colon with a serrated border (arrows), an appearance indicative of invasion by the perirectal mass.
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Figure 3d. Tubo-ovarian actinomycosis in a 44-year-old woman. The TOA has a predominantly solid appearance. (a) Contrast-enhanced CT scan shows a round, solid mass (arrows) in the right adnexal region. Multiple small, rim-enhancing lesions (arrowheads) are seen inside the mass. (b) Contrast-enhanced CT scan obtained caudad to a shows a well-enhancing solid lesion (arrows) extending posteriorly from the mass. (c) Contrast-enhanced CT scan obtained caudad to b shows an enhancing perirectal mass (arrows), which is formed by the lesion extending from the adnexal mass. An IUD is noted (arrowhead). (d) Image from a barium study of the rectosigmoid shows segmental narrowing of the distal sigmoid colon with a serrated border (arrows), an appearance indicative of invasion by the perirectal mass.
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Figure 5a. Tubo-ovarian actinomycosis in a 52-year-old woman. The TOA has a predominantly solid appearance. (a) Contrast-enhanced CT scan shows a solid mass in the left adnexal region (solid arrows). Multiple air bubbles (arrowheads) and rim-enhancing lesions (open arrow) are seen in the mass. (b) Axial T2-weighted MR image shows that the mass (arrows) has low signal intensity with some regions of high signal intensity. (c) Axial contrast-enhanced fat-suppressed T1-weighted MR image shows good enhancement of the mass. The small cystic lesions with enhancing rims (black arrows) are clearly visible inside the mass. The cystic lesion in the right adnexal region (white arrows) is an incidentally found hemorrhagic cyst of the right ovary.
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Figure 5b. Tubo-ovarian actinomycosis in a 52-year-old woman. The TOA has a predominantly solid appearance. (a) Contrast-enhanced CT scan shows a solid mass in the left adnexal region (solid arrows). Multiple air bubbles (arrowheads) and rim-enhancing lesions (open arrow) are seen in the mass. (b) Axial T2-weighted MR image shows that the mass (arrows) has low signal intensity with some regions of high signal intensity. (c) Axial contrast-enhanced fat-suppressed T1-weighted MR image shows good enhancement of the mass. The small cystic lesions with enhancing rims (black arrows) are clearly visible inside the mass. The cystic lesion in the right adnexal region (white arrows) is an incidentally found hemorrhagic cyst of the right ovary.
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Figure 5c. Tubo-ovarian actinomycosis in a 52-year-old woman. The TOA has a predominantly solid appearance. (a) Contrast-enhanced CT scan shows a solid mass in the left adnexal region (solid arrows). Multiple air bubbles (arrowheads) and rim-enhancing lesions (open arrow) are seen in the mass. (b) Axial T2-weighted MR image shows that the mass (arrows) has low signal intensity with some regions of high signal intensity. (c) Axial contrast-enhanced fat-suppressed T1-weighted MR image shows good enhancement of the mass. The small cystic lesions with enhancing rims (black arrows) are clearly visible inside the mass. The cystic lesion in the right adnexal region (white arrows) is an incidentally found hemorrhagic cyst of the right ovary.
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At MR imaging, TOAs from actinomycosis often appear as mainly solid (Fig 5b, 5c) or solid and cystic (Fig 6) masses and show heterogeneous signal intensity on T2-weighted images. The solid component of the mass shows low signal intensity on T2-weighted images, representing a fibrotic process (4,8). Small cystic lesions with enhancing rims suggesting small abscesses can also be found on MR images (Figs 5c, 6b). Direct inflammatory extension by solid and linear lesions is also commonly found; these inflammatory extensions show low signal intensity on T2-weighted images and enhance well (Fig 6).
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Figure 6a. Tubo-ovarian actinomycosis in a 48-year-old woman. The TOA has a solid and cystic appearance. (a) Axial T2-weighted MR image shows a solid and cystic mass in the right adnexal region (black arrows). Note the posterior extension by a solid lesion with low signal intensity (white arrows). (b) Axial contrast-enhanced fat-suppressed T1-weighted MR image obtained caudad to a shows good enhancement of the solid portion of the mass, which has multiple internal rim-enhancing lesions (black arrow). The linear, solid lesion extending posteriorly from the mass (white arrows) is also well enhanced.
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Figure 6b. Tubo-ovarian actinomycosis in a 48-year-old woman. The TOA has a solid and cystic appearance. (a) Axial T2-weighted MR image shows a solid and cystic mass in the right adnexal region (black arrows). Note the posterior extension by a solid lesion with low signal intensity (white arrows). (b) Axial contrast-enhanced fat-suppressed T1-weighted MR image obtained caudad to a shows good enhancement of the solid portion of the mass, which has multiple internal rim-enhancing lesions (black arrow). The linear, solid lesion extending posteriorly from the mass (white arrows) is also well enhanced.
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Less commonly, actinomycotic TOAs appear as thick-walled cystic masses, and differentiation from usual TOAs is very difficult or impossible. However, the invasive features are frequently also seen with these forms (Fig 7).
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Figure 7a. Tubo-ovarian actinomycosis in a 29-year-old woman. The TOA has a predominantly cystic appearance. (a) Axial T2-weighted MR image shows a cystic mass (solid arrows) in the right adnexal region. Note the eccentric wall thickening extending posteriorly into the presacral space (open arrows). (b) Sagittal T2-weighted MR image shows that the distal right ureter (arrows) is encased by the mass. (c) Axial contrast-enhanced fat-suppressed T1-weighted MR image shows that the mass (arrows) has a multilayered wall with good enhancement of the eccentric wall thickening.
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Figure 7b. Tubo-ovarian actinomycosis in a 29-year-old woman. The TOA has a predominantly cystic appearance. (a) Axial T2-weighted MR image shows a cystic mass (solid arrows) in the right adnexal region. Note the eccentric wall thickening extending posteriorly into the presacral space (open arrows). (b) Sagittal T2-weighted MR image shows that the distal right ureter (arrows) is encased by the mass. (c) Axial contrast-enhanced fat-suppressed T1-weighted MR image shows that the mass (arrows) has a multilayered wall with good enhancement of the eccentric wall thickening.
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Figure 7c. Tubo-ovarian actinomycosis in a 29-year-old woman. The TOA has a predominantly cystic appearance. (a) Axial T2-weighted MR image shows a cystic mass (solid arrows) in the right adnexal region. Note the eccentric wall thickening extending posteriorly into the presacral space (open arrows). (b) Sagittal T2-weighted MR image shows that the distal right ureter (arrows) is encased by the mass. (c) Axial contrast-enhanced fat-suppressed T1-weighted MR image shows that the mass (arrows) has a multilayered wall with good enhancement of the eccentric wall thickening.
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At CT and MR imaging, invasion into adjacent organs is more frequently found than in usual TOAs, and hydronephrosis by ureteral invasion or rectosigmoid involvement is very common (Figs 3d, 7b).
There can be high suspicion for the diagnosis of actinomycosis when some characteristic features described in this section are prominent on CT and MR images. However, practical differentiation from ovarian malignancies is difficult in many cases.
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Tuberculosis
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According to a recent study, genital tract involvement was detected in 1.3% of female patients with tuberculosis, and the affected sites were the endometrium (72%), salpinx (34%), ovary (12.9%), and cervix (2.4%) (14). Tubo-ovarian involvement is usually caused by hematogenous or lymphatic spread and occasionally by peritoneal dissemination (15). It can mimic ovarian cancer by both radiologic findings and clinical settings; the symptoms are usually vague, serum CA-125 (cancer antigen 125) levels are usually elevated, and the radiologic findings closely resemble those of ovarian cancer with peritoneal seeding (5,16). Therefore, the definite diagnosis is usually made postoperatively.
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Imaging Findings of TOAs from Tuberculosis
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When overt TOAs are formed by tuberculosis, complex adnexal masses with a large amount of ascites may be demonstrated at sonography, resembling ovarian malignancies with peritoneal seeding. However, sonographic findings can be various according to the stage and the route of this infection and are also nonspecific.
When ovaries and salpinges are affected by generalized peritoneal tuberculosis, tubo-ovarian lesions are usually minimal or even inconspicuous at CT, whereas the findings of tuberculous peritonitis frequently mimic those of peritoneal carcinomatosis. MR imaging is more helpful in revealing tubo-ovarian lesions and may demonstrate thickened salpinges or nodularities along tubo-ovarian surfaces (Fig 8). However, these findings are also nonspecific and differentiation from peritoneal seeding by malignant tumors or primary ovarian malignant tumors such as serous surface papillary carcinomas is difficult in many cases. Some helpful findings suggestive of tuberculous peritonitis are smoother peritoneal thickening at CT and a more regular pattern of small nodularities along the peritoneum at MR imaging (17).
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Figure 8a. Tubo-ovarian involvement by peritoneal tuberculosis in a 14-year-old girl. (a) Sagittal T2-weighted MR image shows diffuse nodular thickening of the peritoneum (arrows) with a large amount of ascites. In addition, small nodular lesions (arrowheads) are seen on the surface of the ovary. (b) Axial T2-weighted MR image shows the thickened right salpinx (black arrows) surrounding the ovary (white arrows). The thickened salpinx has low signal intensity. (c) Axial contrast-enhanced fat-suppressed T1-weighted MR image shows good enhancement of both thickened salpinges (white arrows), the surface of the right ovary (black arrows), and the peritoneum (arrowheads).
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Figure 8b. Tubo-ovarian involvement by peritoneal tuberculosis in a 14-year-old girl. (a) Sagittal T2-weighted MR image shows diffuse nodular thickening of the peritoneum (arrows) with a large amount of ascites. In addition, small nodular lesions (arrowheads) are seen on the surface of the ovary. (b) Axial T2-weighted MR image shows the thickened right salpinx (black arrows) surrounding the ovary (white arrows). The thickened salpinx has low signal intensity. (c) Axial contrast-enhanced fat-suppressed T1-weighted MR image shows good enhancement of both thickened salpinges (white arrows), the surface of the right ovary (black arrows), and the peritoneum (arrowheads).
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Figure 8c. Tubo-ovarian involvement by peritoneal tuberculosis in a 14-year-old girl. (a) Sagittal T2-weighted MR image shows diffuse nodular thickening of the peritoneum (arrows) with a large amount of ascites. In addition, small nodular lesions (arrowheads) are seen on the surface of the ovary. (b) Axial T2-weighted MR image shows the thickened right salpinx (black arrows) surrounding the ovary (white arrows). The thickened salpinx has low signal intensity. (c) Axial contrast-enhanced fat-suppressed T1-weighted MR image shows good enhancement of both thickened salpinges (white arrows), the surface of the right ovary (black arrows), and the peritoneum (arrowheads).
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Tuberculous salpingitis is usually caused by hematogenous or lymphatic spread, and when it progresses and involves the ovaries, tuberculous TOAs can be formed. Peritonitis is frequently associated, and coexisting endometritis may be found (Fig 9). Cystic or both solid and cystic adnexal masses, usually bilateral, are accompanied by ascites, omental or mesenteric infiltrations, and peritoneal thickening. These findings closely resemble those of peritoneal carcinomatosis from ovarian cancer (Figs 10, 11). Calcifications may be found in adnexal masses at CT and suggest tuberculosis (Fig 11a) but are not frequently observed, especially in active inflammation. Lymph node enlargement is common, and necrotic lymph nodes suggesting tuberculous lymphadenitis may be found (18,19).
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Figure 9a. Tuberculous TOAs with endometritis in a 63-year-old woman. (a) Sagittal contrast-enhanced T1-weighted MR image shows a well-enhancing, thickened endometrium (arrows) with hydrometra. (b) Axial contrast-enhanced T1-weighted MR image shows septate cystic masses (arrows) in both adnexal regions.
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Figure 9b. Tuberculous TOAs with endometritis in a 63-year-old woman. (a) Sagittal contrast-enhanced T1-weighted MR image shows a well-enhancing, thickened endometrium (arrows) with hydrometra. (b) Axial contrast-enhanced T1-weighted MR image shows septate cystic masses (arrows) in both adnexal regions.
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Figure 10a. Tuberculous TOAs in a 22-year-old woman. (a) Axial T2-weighted MR image shows predominantly cystic masses (white arrows) in both adnexal regions. The walls and septa have low signal intensity and are irregularly thickened. Another septate cystic mass (black arrows) is seen between the two adnexal masses. Note the infiltrations in the anterior peritoneal fat planes (bottom arrowheads) and the peritoneal thickening (top arrowheads). (b) Axial T1-weighted MR image shows that the inner walls and septa (arrowheads) of both adnexal masses (white arrows) have slightly high signal intensity. Some of the contents of the right adnexal mass also have high signal intensity (black arrow). (c) Axial contrast-enhanced fat-suppressed T1-weighted MR image shows marked enhancement of the walls and septa of the adnexal masses. There is prominent enhancement of the peritoneal thickening and the infiltrations in the peritoneal fat planes (arrows). (d) Sagittal contrast-enhanced T1-weighted MR image shows serrations or small nodular lesions (arrowheads) along the inner wall of the left adnexal mass (arrows). (e) Contrast-enhanced CT scan shows loculated fluid collections with enhancing walls (arrows) in the perihepatic space.
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Figure 10b. Tuberculous TOAs in a 22-year-old woman. (a) Axial T2-weighted MR image shows predominantly cystic masses (white arrows) in both adnexal regions. The walls and septa have low signal intensity and are irregularly thickened. Another septate cystic mass (black arrows) is seen between the two adnexal masses. Note the infiltrations in the anterior peritoneal fat planes (bottom arrowheads) and the peritoneal thickening (top arrowheads). (b) Axial T1-weighted MR image shows that the inner walls and septa (arrowheads) of both adnexal masses (white arrows) have slightly high signal intensity. Some of the contents of the right adnexal mass also have high signal intensity (black arrow). (c) Axial contrast-enhanced fat-suppressed T1-weighted MR image shows marked enhancement of the walls and septa of the adnexal masses. There is prominent enhancement of the peritoneal thickening and the infiltrations in the peritoneal fat planes (arrows). (d) Sagittal contrast-enhanced T1-weighted MR image shows serrations or small nodular lesions (arrowheads) along the inner wall of the left adnexal mass (arrows). (e) Contrast-enhanced CT scan shows loculated fluid collections with enhancing walls (arrows) in the perihepatic space.
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Figure 10c. Tuberculous TOAs in a 22-year-old woman. (a) Axial T2-weighted MR image shows predominantly cystic masses (white arrows) in both adnexal regions. The walls and septa have low signal intensity and are irregularly thickened. Another septate cystic mass (black arrows) is seen between the two adnexal masses. Note the infiltrations in the anterior peritoneal fat planes (bottom arrowheads) and the peritoneal thickening (top arrowheads). (b) Axial T1-weighted MR image shows that the inner walls and septa (arrowheads) of both adnexal masses (white arrows) have slightly high signal intensity. Some of the contents of the right adnexal mass also have high signal intensity (black arrow). (c) Axial contrast-enhanced fat-suppressed T1-weighted MR image shows marked enhancement of the walls and septa of the adnexal masses. There is prominent enhancement of the peritoneal thickening and the infiltrations in the peritoneal fat planes (arrows). (d) Sagittal contrast-enhanced T1-weighted MR image shows serrations or small nodular lesions (arrowheads) along the inner wall of the left adnexal mass (arrows). (e) Contrast-enhanced CT scan shows loculated fluid collections with enhancing walls (arrows) in the perihepatic space.
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Figure 10d. Tuberculous TOAs in a 22-year-old woman. (a) Axial T2-weighted MR image shows predominantly cystic masses (white arrows) in both adnexal regions. The walls and septa have low signal intensity and are irregularly thickened. Another septate cystic mass (black arrows) is seen between the two adnexal masses. Note the infiltrations in the anterior peritoneal fat planes (bottom arrowheads) and the peritoneal thickening (top arrowheads). (b) Axial T1-weighted MR image shows that the inner walls and septa (arrowheads) of both adnexal masses (white arrows) have slightly high signal intensity. Some of the contents of the right adnexal mass also have high signal intensity (black arrow). (c) Axial contrast-enhanced fat-suppressed T1-weighted MR image shows marked enhancement of the walls and septa of the adnexal masses. There is prominent enhancement of the peritoneal thickening and the infiltrations in the peritoneal fat planes (arrows). (d) Sagittal contrast-enhanced T1-weighted MR image shows serrations or small nodular lesions (arrowheads) along the inner wall of the left adnexal mass (arrows). (e) Contrast-enhanced CT scan shows loculated fluid collections with enhancing walls (arrows) in the perihepatic space.
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Figure 10e. Tuberculous TOAs in a 22-year-old woman. (a) Axial T2-weighted MR image shows predominantly cystic masses (white arrows) in both adnexal regions. The walls and septa have low signal intensity and are irregularly thickened. Another septate cystic mass (black arrows) is seen between the two adnexal masses. Note the infiltrations in the anterior peritoneal fat planes (bottom arrowheads) and the peritoneal thickening (top arrowheads). (b) Axial T1-weighted MR image shows that the inner walls and septa (arrowheads) of both adnexal masses (white arrows) have slightly high signal intensity. Some of the contents of the right adnexal mass also have high signal intensity (black arrow). (c) Axial contrast-enhanced fat-suppressed T1-weighted MR image shows marked enhancement of the walls and septa of the adnexal masses. There is prominent enhancement of the peritoneal thickening and the infiltrations in the peritoneal fat planes (arrows). (d) Sagittal contrast-enhanced T1-weighted MR image shows serrations or small nodular lesions (arrowheads) along the inner wall of the left adnexal mass (arrows). (e) Contrast-enhanced CT scan shows loculated fluid collections with enhancing walls (arrows) in the perihepatic space.
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Figure 11a. Tuberculous TOA in a 52-year-old woman. (a) Unenhanced CT scan shows a right adnexal mass (white arrows) with multiple internal calcifications (black arrows). (b) Contrast-enhanced CT scan shows that the adnexal mass (white arrows) is predominantly cystic with an irregular, thick, well-enhancing wall. In addition, a lobulated cystic mass (black arrows) with thin internal septa is seen posterior to the adnexal mass. The solid mass in the left adnexal region (arrowheads) is an incidentally found ovarian Brenner tumor. (c) Sagittal T2-weighted MR image shows low signal intensity of the wall and septa of the right adnexal mass (white arrows). Note the small nodular lesions along the inner wall (black arrows). (d, e) Sagittal contrast-enhanced T1-weighted MR images show marked enhancement of the wall and septa of the right adnexal mass (white arrows in d). Adhesion to the uterus (U) is clearly demonstrated (black arrows in d). In addition, a multiseptate cystic lesion (arrows in e) is seen in the cul-de-sac.
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Figure 11b. Tuberculous TOA in a 52-year-old woman. (a) Unenhanced CT scan shows a right adnexal mass (white arrows) with multiple internal calcifications (black arrows). (b) Contrast-enhanced CT scan shows that the adnexal mass (white arrows) is predominantly cystic with an irregular, thick, well-enhancing wall. In addition, a lobulated cystic mass (black arrows) with thin internal septa is seen posterior to the adnexal mass. The solid mass in the left adnexal region (arrowheads) is an incidentally found ovarian Brenner tumor. (c) Sagittal T2-weighted MR image shows low signal intensity of the wall and septa of the right adnexal mass (white arrows). Note the small nodular lesions along the inner wall (black arrows). (d, e) Sagittal contrast-enhanced T1-weighted MR images show marked enhancement of the wall and septa of the right adnexal mass (white arrows in d). Adhesion to the uterus (U) is clearly demonstrated (black arrows in d). In addition, a multiseptate cystic lesion (arrows in e) is seen in the cul-de-sac.
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Figure 11c. Tuberculous TOA in a 52-year-old woman. (a) Unenhanced CT scan shows a right adnexal mass (white arrows) with multiple internal calcifications (black arrows). (b) Contrast-enhanced CT scan shows that the adnexal mass (white arrows) is predominantly cystic with an irregular, thick, well-enhancing wall. In addition, a lobulated cystic mass (black arrows) with thin internal septa is seen posterior to the adnexal mass. The solid mass in the left adnexal region (arrowheads) is an incidentally found ovarian Brenner tumor. (c) Sagittal T2-weighted MR image shows low signal intensity of the wall and septa of the right adnexal mass (white arrows). Note the small nodular lesions along the inner wall (black arrows). (d, e) Sagittal contrast-enhanced T1-weighted MR images show marked enhancement of the wall and septa of the right adnexal mass (white arrows in d). Adhesion to the uterus (U) is clearly demonstrated (black arrows in d). In addition, a multiseptate cystic lesion (arrows in e) is seen in the cul-de-sac.
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Figure 11d. Tuberculous TOA in a 52-year-old woman. (a) Unenhanced CT scan shows a right adnexal mass (white arrows) with multiple internal calcifications (black arrows). (b) Contrast-enhanced CT scan shows that the adnexal mass (white arrows) is predominantly cystic with an irregular, thick, well-enhancing wall. In addition, a lobulated cystic mass (black arrows) with thin internal septa is seen posterior to the adnexal mass. The solid mass in the left adnexal region (arrowheads) is an incidentally found ovarian Brenner tumor. (c) Sagittal T2-weighted MR image shows low signal intensity of the wall and septa of the right adnexal mass (white arrows). Note the small nodular lesions along the inner wall (black arrows). (d, e) Sagittal contrast-enhanced T1-weighted MR images show marked enhancement of the wall and septa of the right adnexal mass (white arrows in d). Adhesion to the uterus (U) is clearly demonstrated (black arrows in d). In addition, a multiseptate cystic lesion (arrows in e) is seen in the cul-de-sac.
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Figure 11e. Tuberculous TOA in a 52-year-old woman. (a) Unenhanced CT scan shows a right adnexal mass (white arrows) with multiple internal calcifications (black arrows). (b) Contrast-enhanced CT scan shows that the adnexal mass (white arrows) is predominantly cystic with an irregular, thick, well-enhancing wall. In addition, a lobulated cystic mass (black arrows) with thin internal septa is seen posterior to the adnexal mass. The solid mass in the left adnexal region (arrowheads) is an incidentally found ovarian Brenner tumor. (c) Sagittal T2-weighted MR image shows low signal intensity of the wall and septa of the right adnexal mass (white arrows). Note the small nodular lesions along the inner wall (black arrows). (d, e) Sagittal contrast-enhanced T1-weighted MR images show marked enhancement of the wall and septa of the right adnexal mass (white arrows in d). Adhesion to the uterus (U) is clearly demonstrated (black arrows in d). In addition, a multiseptate cystic lesion (arrows in e) is seen in the cul-de-sac.
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At MR imaging, the walls of tuberculous TOAs are often irregular and show low signal intensity on T2-weighted images (Fig 10). Compared with usual TOAs, in which the wall thickening is usually uniform, tuberculous TOA may show a serrated or nodular inner wall, reminiscent of nodular thickening of the peritoneum by tuberculous peritonitis (Figs 10d, 11c). Dense adhesion with the uterus or other adjacent organs is common and may reflect a late fibrotic process of this infection (Fig 11d). Loculated fluid collections with internal septations are often found adjacent to the masses or in the cul-de-sac (Figs 10a, 11e), as well as in other portions of the peritoneal cavity (Fig 10e).
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Xanthogranulomatous Inflammation
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Abstract
LEARNING OBJECTIVES FOR TEST...
