Massive Ascites of Unknown Origin: A Case Report

Ascites is the excessive accumulation of fluid in the peritoneal cavity and predominantly caused by liver cirrhosis, cancers, or heart failure. In this study, a 31-year-old woman with chronic renal failure of unknown etiology treated with hemodialysis and peritoneal dialysis was often hospitalized because of ascites, which appeared 4 years after the second kidney transplantation. The patient was regularly (every 2-3 weeks) treated with paracentesis. Peritoneal fluid tested negative for bacterial (including atypical) and fungal infections and tuberculosis. Doppler ultrasound and liver FibroScan did not show any irregularities. Computed tomography (CT) revealed an enlarged left ovary. A high level of CA 125 was found. The second diagnostic laparoscopy revealed no changes in the ovaries, and there were no tumor cells. Diagnostics were extended, but no deviations were revealed. Suspecting drug etiology, mycophenolic acid was discontinued, bringing no improvement. Diagnostic tests caused suspicion of Meigs' syndrome; therefore, oophorectomy of left ovary was conducted, revealing numerous small cysts filled with serous fluid, without tumor cells in the ovary or peritoneal fluid. Despite the procedure performed, ascites was recurrent. Five month later, ascites spontaneously stopped growing. Paracentesis to decompress ascites was no longer required. There were 9 paracenteses performed from oophorectomy (the latest on May 23, 2019). The need for repetitive paracentesis, significantly reducing the patient's quality of life, required diagnosis for casuistic diseases. The described case is atypical because of the confusing etiology of ascites and its spontaneous cessation. Despite numerous examinations and recession of ascites, the cause of the problem is not entirely clear.

Demons syndrome revisited: a review of the literature

OBJECTIVES

To report various descriptions of the combination of a benign genital tumour with pleural and/or abdominal effusion throughout the years and to determine the paternity of this syndrome, commonly known as Meigs' syndrome.

METHODS

A systematic review of the literature from 1728 to 2004.

RESULTS

Before 1880, publications were rare and limited to clinical and anatomical descriptions drawing no conclusions between the cause and effect of this condition and even less about its management. Demons described the syndrome between 1887 and 1902. He was the first to specify that removal of the tumour (benign ovarian cyst, solid ovarian tumour, fibroma of the broad ligament) was essential for the patient to be cured of the effusions and that it was wrong to postpone surgery. In 1937, Meigs arrived at the same findings concerning ovarian fibromas and granulosa cell tumours, hence the name of Demons-Meigs which was given to this syndrome with the agreement of Meigs. Current literature reports on pseudosyndromes of Demons-Meigs including genital malignancies with negative cytology. These entities should not be called Demons or Meigs pseudosyndromes. Inversely, all benign tumours of the genital tract should be included in Demons syndrome, even if Demons did not actually encounter any during his years of practice, but it was in the spirit of his observations.

CONCLUSION

Demons' syndrome includes all benign genital tumours, the Demons-Meigs eponym is reserved for the description of ovarian fibromas and granulosa cell tumours, and the Demons' pseudosyndrome includes all other entities.

Pseudo-Meigs' syndrome caused by breast cancer metastasis to both ovaries

We report a rare case of pseudo-Meigs' syndrome due to metastasis of breast cancer to both ovaries. A 34-year-old woman with exertional dyspnea was admitted to our hospital. Before entry the patient had undergone radical mastectomy for left breast cancer in June 1998. Resection and reconstruction of the chest wall for recurrence of the breast cancer had been performed in April 2001. Right pleural effusion was found on admission to our hospital in October 2002. Continuous thoracic drainage obtained 500-2000 ml of fluid per day. Cytologic results were both normal and benign, and cultures for bacteria and acid-fast bacilli were negative. During treatment of the pleural effusion, which proved to be cryptogenic and intractable, a huge pelvic tumor was found. The primary site was unknown. Surgery was performed in November 2002, and tumors were removed from both ovaries. The right pleural effusion vanished after surgery. Pseudo-Meigs' syndrome with metastasis of breast cancer to both ovaries was diagnosed. The patient died of cachexia related to the carcinoma in January 2005.

Meig's or Pseudomeig's syndrome?

The triad of ascites, hydrothorax in association with a benign ovarian tumor is defined as Meig's syndrome. It is a rare clinical entity. A case of a 62 year-old woman whith dyspnoe, abdominal discomfort and ascites is presented. Clinical and ultrasonographic findings revealed extended palpable pelvic mass originating from the ovaries and ascites as well as hydrothorax of the left lung by chest radiography. The treatment method was surgical intervention. Cytomorphologic studies were positive for malignacy and adenocarcinoma cells were confirmed. The pathogenesis of the pleural and ascites fluids and the importance of CA-125 are discussed (Fig. 2, Ref. 21).

Elevated CA125 level associated with Meigs' syndrome: case report and review of the literature

Meigs' syndrome is the association of ovarian fibroma, pleural effusion, and ascites. Meigs' syndrome with marked elevation of CA125 is an unusual clinical condition reported in 27 cases in the literature. The patient was a 46-year-old woman with right pleural effusion, ascites, ovarian tumor, and CA125 level of 1808 U/mL. Tomography revealed ascites and bilobate pelvic tumor of approximately 25 cm. The diagnosis of advanced epithelial ovarian cancer was considered, and the patient was treated with chemotherapy. Three chemotherapy schemes were applied due to the total lack of response in tumor volume; however, CA125 decreased to 90 U/mL. Thus, surgery was performed with resection of 25 cm of the left ovarian tumor, with intact capsule and without implants; the result of histopathologic analysis was fibroma. Postoperative CA125 was 11 U/mL. Patients with elevated CA125 and ascites cytology positive for malignancy must be cautiously treated due to the possibility of false positives, even if the probability is low. Therefore, minimally invasive surgery for biopsy collection must be considered. Although the association between ovarian tumor, pleural effusion, ascites, and marked elevation of CA125 is highly indicative of epithelial ovarian cancer, Meigs' syndrome must be considered in the differential diagnosis.

[The lung and benign diseases of the ovary]

Two main benign diseases of the ovary which can simulate advanced stage cancer of the ovary are described. The first is Meigs' syndrome, a triad of benign ovarian tumor, usually an ovarian fibroma, ascitis, and pleural effusion with complete disappearance of serous exsudative effusions with surgical resection of the ovarian tumor. The second is ovarian hyperstimulation syndrome following ovulation induction with exogenous gonotropins for the treatment of infertility. This syndrome associates significant ovarian enlargement, hyperestrogenism and latent or clinically patent serous exsudative effusions; it usually resolves with suggestive measures and rest.

[Deimons-Meigs syndrome and elevated CA-125: diagnosis of ovarian cancer and therapeutic implications]

Regarding a original observation of the Deimons-Meigs syndrome, the authors have derived, from a review of the literature, the main clinicals and etiopathogenics characteristics, and tried to discuss the terms and conditions of a therapeutic treatment appropriate to such a situation.

[Meigs syndrome with bilateral hydrothorax]

The co-existence of pelvic tumor, hydrothorax and ascites has been known since the last century. The features of this disease were described by Meigs and Cass in 1937; in the same year Roads named it Meigs syndrome. According to the original description this syndrome only included, as pelvic involvement, an ovarian neoplasm; at present it is accepted that hydrothorax and the ascites can also be associated with a uterine tumor, like a fibroma. The existence of either an ovarian or a uterine neoplasm distinguishes the typical Meigs syndrome from a pseudo-Meigs syndrome. The most likely pathogenesis of Meigs syndrome ascribes the formation of the peritoneal and pleural effusion to the filtration of interstitial fluid in the peritoneum through the tumor capsule, and the diffusion to the pleural space, generally at the right side, through the diaphragm lymphatic vessels and the foramen of Bochdalek. Dockerty reported that at least 40% of ovarian tumors had a diameter of more than 6 cm when associated with hydrothorax and ascites. The entity of pleural and peritoneal effusion can be moderate or massive. The effusions generally derive from a transudative process, but they can occasionally contain blood cells. The connection between the pelvic tumor and the effusion is demonstrated by the regression of the latter when the neoplasm is excised. When the pelvic tumor has an ovarian location it derives from the connective tissue of the hilus, it appears during fertile age and has a slow growth, the clinical signs becoming evident in elder age.

Meigs' syndrome--a case report

Bilateral ovarian fibromas combined with as and hydrothorax is a rare disorder. A case of bilateral ovarian fibromas combined with ascites and hyrothorax is presented. The ascites and hydrothorax disappeared spontaneously after removal of the ovarian tumors.