An 18 year old girl presents with a history of low – grade fever, weight loss, abdominal pain and amenorrhoea for six months. On examination, a pelvic mass is felt on the left side and signs of ascites are positive. What is your diagnosis ?

Correct Answer: C. Tuberculosis with tubo – ovarian mass

The clinical presentation of a young woman with a 6-month history of low-grade fever, weight loss, abdominal pain, amenorrhoea, pelvic mass, and ascites is pathognomonic for genital tuberculosis with tubo-ovarian involvement. In India, where TB prevalence remains high, genital TB accounts for 8–15% of infertility cases and commonly presents with this constellation of constitutional symptoms. The chronic nature (6 months) rules out acute processes. The amenorrhoea results from endometrial involvement causing Asherman-like syndrome or ovarian dysfunction. The pelvic mass represents a tuberculous tubo-ovarian complex—typically unilateral (left side here), with caseating granulomas visible on histology. Ascites develops due to peritoneal involvement and inflammation. Diagnosis is confirmed by endometrial biopsy showing caseating granulomas, TB culture (slow-growing), or PCR. The key discriminator is the chronic systemic symptoms (fever, weight loss) combined with reproductive tract involvement and ascites—a triad highly specific for TB in the Indian context. Treatment follows RNTCP guidelines: standard 4-drug regimen (HRZE) for 2 months followed by HR for 7 months, with adjunctive management of infertility post-cure.

Why the other options are wrong

A. Ectopic pregnancy — Ectopic pregnancy presents acutely with severe pain, vaginal bleeding, and haemodynamic instability; it does not cause 6-month fever, weight loss, or ascites. Amenorrhoea in ectopic pregnancy is due to pregnancy itself (positive hCG), not endometrial pathology. The chronic systemic symptoms and pelvic mass are incompatible with ectopic pregnancy, which is a surgical emergency, not a chronic disease. B. Submucous fibroid — Submucous fibroids cause menorrhagia or metrorrhagia, not amenorrhoea lasting 6 months. They do not produce fever, weight loss, or ascites—these are systemic inflammatory/infectious features absent in benign uterine pathology. Fibroids are structural lesions without constitutional symptoms. The clinical picture of chronic infection with ascites excludes fibroid as the diagnosis. D. Ovarian malignancy — While ovarian cancer can present with pelvic mass and ascites, it typically presents in older women (peak 50–60 years) and causes rapid weight loss with acute symptoms. The 6-month low-grade fever is atypical for malignancy; ovarian cancer presents with constitutional symptoms but not the chronic fever pattern seen in TB. Amenorrhoea is not a primary feature of ovarian malignancy. The chronic infectious picture (fever + weight loss) favours TB over malignancy.

High-Yield Facts

Mnemonics

**FEVER-TB (Genital TB red flags) Fever (low-grade, chronic) + Endometrial involvement (amenorrhoea) + Vaginal/pelvic mass + Excudative ascites + Reproductive tract pathology = TB in high-burden settings. CAST (Genital TB diagnosis) Caseating granulomas (biopsy) + Ascites + Systemic symptoms (fever, weight loss) + T**ubo-ovarian mass = Genital TB until proven otherwise.

NBE Trap

NBE pairs "pelvic mass + ascites" with ovarian malignancy to trap students unfamiliar with TB epidemiology in India. The chronic fever and weight loss are the discriminators—malignancy presents acutely; TB is insidious and systemic.

Clinical Pearl

In any Indian woman presenting with infertility, amenorrhoea, or pelvic mass accompanied by constitutional symptoms (fever, weight loss), genital TB must be ruled out first—it is the most common cause of secondary infertility in India and is curable with standard RNTCP chemotherapy if diagnosed early.

_Reference: DC Dutta's Textbook of Gynaecology (6th ed.), Ch. 16 (Genital Tuberculosis); Harrison's Principles of Internal Medicine, Ch. 165 (Tuberculosis)_