pelvic inflammatory disease ( pid ) is a common disorder of the upper female genital tract that can lead to formation of abscesses and peritonitis . in about two thirds of all reported cases , otherwise , it is often associated with sexually transmitted diseases ( stds ) , such as neisseria gonorrhoeae and chlamydia trachomatis infection , and is normally an ascending infection . sometimes it is facilitated by postsurgical and post - delivery conditions or intrauterine devices ( iuds ) , especially shortly after insertion . haematogenous spread can occur but is clinically rare and therefore thought to be of minor relevance . one of the worldwide major infections is tuberculosis ( tb ) and particularly an increasing global health problem with an estimated 1.7 billion infected individuals . however , extrapulmonary infections , such as primary genital tuberculosis , are not very common in developed countries . lymphatic and haematogenous dissemination to parts of the body other than the lung is possible . underlying immunosuppressive diseases favor opportunistic infections and can be associated with pelvic inflammatory disease ( pid ) in these patients . in this regard , the best - known sexually transmitted pathogen is the retrovirus human immunodeficiency virus ( hiv ) . main targets of this pathogenic agent are cd4 + t cells , helper t cells , as well as macrophages and dendritic cells , resulting in a significant decline of cd4 + t cell populations . an hiv infection makes patients more susceptible for further gynaecological infectious diseases including tuberculosis due to their immunosuppressed status [ 5 , 6 ] . here , we present a case about a 35-year - old , hiv - positive patient admitted to our hospital with fever and pain in the lower left abdominal quadrant , with a tuboovarial abscess caused by mycobacterium tuberculosis ( m. tb ) . a 35-year - old woman of african descent with chronic alcohol and nicotine abuse was admitted to our hospital in november 2007 with a two - day history of lower left - sided abdominal pain as well as febrile temperatures of 38.8c and elevated inflammation parameters . her past medical history included hiv infection that was first diagnosed in 2001 and treated with a combination of lamivudin 150  mg plus zidovudin 300  mg ( combivir ) and efavirenz 50  mg/200  mg ( sustiva ) . in that same year , the patient underwent surgery ( a longitudinal incision laparotomy ) for an ovarian cyst . the patient did not tolerate antiretroviral treatment ( due to side effects ) and stopped taking her hiv medication in 2006 , one year prior to her current admission . in november 2007 , the viral load was 59.000  copies / ml and cd4 count was 13% or 159  cells/l . as a secondary finding , a chronic hepatitis b infection with a low viral load was detected during this hospitalization , whereas a hepatitis c infection was excluded . a 5  6  cm cystic mass lesion in the area of the left adnexa could be displayed ( figure 1 ) . several surgical procedures including laparoscopy with subsequent drainage , laparotomy , exstirpation of the cyst , and one - sided ovarectomy were discussed with the patient . first , a diagnostic laparoscopy was performed , revealing several intraabdominal adhesions of the intestine as well as a severe pus - filled abdominal cavity . therefore , a median longitudinal laparotomy had to be performed . after taking microbial samples , afterwards , a tubectomy on the left side was performed and a drainage system was inserted . following the operation , an intravenous antibiotic therapy with ciprofloxacin and metronidazol was started and the pelvis minor was rinsed twice daily . ten days later , the patient was discharged from the hospital in a good general state of health . due to the known hiv - infection , detailed analysis of pus obtained during the operation was necessary . in spite of this , cultures for aerobic and anaerobic microbes , cultures of mycobacterium tuberculosis , as well as chlamydia trachomatis and chlamydia pneumoniae were negative . histopathological studies showed a granulomatous salpingitis with central necrosis of the left fallopian tube ( figure 2 ) and subsequent pcr demonstrated evidence for m. tb - complex specific pcr products . special stains ( ziehl - neels en and auramin ) for acid - fast organisms remained negative . interestingly , chest x - ray analysis performed days after the surgical procedure did not demonstrate any signs of tuberculous involvement of the lung . because of her underlying hiv disease , the patient was referred to our infectious diseases unit and was treated according to current recommendations   with a standardized short - course chemotherapeutic regimen of isoniazid / vitamin b and rifampicin for 6 months and pyrazinamid and ethambutol for 2 months . due to her low cd4 counts ( 170  cells/l = 12% ) prophylactic antibiotic therapy with cotrimoxazole was initiated ( this has been shown to decrease mortality in hiv / tb- coinfected patients ) . she responded promptly to antibiotic therapy as evidenced by declining liver enzymes and crp after two , three , and seven weeks , respectively . initiation of an antiretroviral treatment ( art ) against hiv was to be started at a later time point ( between 2 weeks and 2 months later ) in order to not interfere with tuberculosis regimens . tuberculosis is a global burden since one - third of the world 's population is estimated to be infected with mycobacterium tuberculosis . by contrast , moreover , it is very rarely the cause of pelvic inflammatory disease in developed countries . most of these are host factors causing impaired immunity , whereas increased exposure to the infection is also considered to be a risk factor . genital tract tb is more likely in non - hispanic black patients , patients under 40 years of age , and patients with a history of alcoholism ( alcohol abuse ) . in fact , in developed countries extrapulmonary tuberculosis in the setting of hiv infection is classified as an aids - defining condition ( stage 4 ) . further , patients with cd4 counts < 200  cells/l are at substantially higher risk of tuberculosis compared to those with higher counts . genital tuberculosis ( gtb ) secondary infection by haematogenous spread causes the majority of gtb , but rare occurrences of primary inoculation during sexual intercourse with an infected partner suffering from tuberculous lesions of genitalia are reported . in almost 100% of the cases , the fallopian tubes are affected , followed by endometrial ( 50% ) and ovarian involvement ( 20% ) , whereas infection of the external genitalia occurs in less than 5% of cases . usually , these patients present with a history of involuntary infertility [ 15 , 16 ] , uterine haemorrhage [ 11 , 17 ] , or typical symptoms of pid like pelvic pain , fever , and menstrual disturbances or vaginal discharge [ 3 , 11 , 1517 ] . patients suffering from immunosuppressive diseases like hiv , aplastic anaemia , and alcoholism are considered at high risk for genital tuberculosis . the diagnosis of gtb is a clinical challenge and is rarely pin - pointed by clinical symptoms because of their low specificity . moreover , elaborate examinations ( pelvic ultrasound , chest x - ray , mantoux test , bacteriological cultivation , ziehl - neelson staining for acid fast bacilli , pcr analysis , pathohistologic evaluation ) including invasive surgical procedures such as diagnostic laparoscopy often have to be carried out for diagnosing tb . however , even negative results can not rule out a tuberculous infection , since up to 92% of chest x - rays , over 90% of ziehl - neels on stains and even pathological examinations can be negative in a patient with tuberculosis infection . interestingly , the most likely reason for the absence of pulmonary abnormalities is that in immunocompetent patients most lesions of primary and disseminated tb can heal . however , the remaining cavities can be potential foci of a later reactivation or may even be the cause of spreading through the blood stream . this case report illustrates that patients with impaired immunity might also have an eptb manifestation without a subsequent focus . current treatment recommendations include isoniazid , rifampin , and pyrazinamide as basic regimen complemented usually by ethambutol as a fourth agent for a 2-month period and the first two agents for an additional 4 months . nonetheless , genitourinary tuberculosis has been reported to have high rate of treatment failure , particularly in advanced stages of the disease . therefore , every attending gynaecological physician should be aware of the possibility of tuberculosis as a cause of pelvic inflammatory disease ( pid ) . in patients with risk factors such as hiv - positivity , alcoholism , intravenous drug abuse ( ivda ) , and other immunosuppressive diseases , tubo - ovarian abscesses ( toa ) caused by tuberculous pathogens should be considered .
background . 
 although tuberculosis ( tb ) is a major health problem worldwide , primary 
 extrapulmonary tuberculosis ( eptb ) , and in particular female genital tract infection , remains a rare 
 event . 
 case report . a 35-year - old human immunodeficiency virus ( hiv ) 
 seropositive woman of african descent with lower abdominal pain and fever of two days duration underwent surgery due to left adnexal mass suggesting pelvic inflammatory disease . 
 the surgical situs showed a four 
 quadrant peritonitis , consistent with the clinical symptoms of the patient , provoked by a tuboovarian 
 abscess ( toa ) on the left side . 
 all routine diagnostic procedures failed to determine the causative 
 organism / pathogen of the infection . 
 histopathological evaluation identified a necrotic 
 granulomatous salpingitis and specific pcr analysis corroborated mycobacterium tuberculosis ( m. tb ) . 
 consequently , antituberculotic therapy was provided . conclusion . in the differential diagnosis of pelvic inflammatory disease 
 , internal genital tuberculosis should be considered . 
 moreover , physicians should consider tuberculous infections early in the work - up of patients when immunosuppressive conditions are present .