Unveiling the Conundrum: Genital Tuberculosis with Omental Tubercles and Uterine Leiomyoma Masquerading as Malignancy.

Female genital tuberculosis (TB) is an uncommon form of extrapulmonary TB that may closely mimic advanced gynecological malignancy because of overlapping clinical, radiological, and biochemical findings. We report the case of a 70-year-old woman who presented with abdominal distension, pelvic pain, weight loss, elevated CA-125 levels, and omental nodularity suggestive of peritoneal carcinomatosis. Imaging revealed an enlarged uterus with an intramural mass and multiple peritoneal deposits, raising strong suspicion for ovarian or primary peritoneal malignancy. Diagnostic laparoscopy demonstrated multiple whitish tubercles involving the omentum, peritoneum, bowel wall, and uterine surface. Histopathological examination of hysterectomy, omentectomy, and peritoneal biopsy specimens revealed caseating granulomatous inflammation with Langhans giant cells involving the myometrium, cervix, omentum, and peritoneum, while the uterine mass was confirmed as leiomyoma. Subsequent microbiological evaluation established the diagnosis of Mycobacterium tuberculosis. The patient responded favorably to anti-tubercular therapy. This case highlights the diagnostic challenge posed by genital and peritoneal TB in elderly patients, particularly when accompanied by elevated tumor markers and incidental uterine leiomyoma. Early histopathological confirmation and awareness of this entity are essential to avoid unnecessary radical surgical procedures and ensure timely initiation of appropriate therapy.