|Year : 2017 | Volume
| Issue : 2 | Page : 74-76
Isolated tuberculous epididymitis
Department of Urology, Heping Campus, Taipei City Hospital, Section 2, Taipei 10065, Taiwan
|Date of Submission||01-Aug-2016|
|Date of Decision||04-Oct-2016|
|Date of Acceptance||14-Oct-2016|
|Date of Web Publication||18-Apr-2017|
Department of Urology, Heping Campus, Taipei City Hospital, 33, Section 2, Chung Hwa Road, Taipei 10065
Source of Support: None, Conflict of Interest: None
Isolated tuberculous epididymitis (ITE) is an uncommon disease that is often incorrectly diagnosed as the more common epididymo-orchitis. ITE is usually treated using long-term general parenteral or oral antibiotics. The nonspecific nature of laboratory tests for ITE renders its diagnosis challenging. Here, we report the case of a 65-year-old male patient who presented with a 6-month history of the left scrotal swelling. He was initially treated with general oral antibiotics but without any noticeable improvement. On the basis of his symptoms and signs, laboratory test and imaging results, and biopsy, we finally made a diagnosis of ITE. After receiving appropriate treatment, the patient was cured completely without the need of surgical intervention.
Keywords: Epididymis, extrapulmonary tuberculosis, tuberculosis
|How to cite this article:|
Chen SM. Isolated tuberculous epididymitis. Formos J Surg 2017;50:74-6
| Introduction|| |
Tuberculosis (TB) is a systemic infection caused by the acid-fast bacterium Mycobacterium tuberculosis. TB is transmitted by coughed aerosol and usually presents with respiratory symptoms. However, after pulmonary infection, M. tuberculosis can infect any other organ system through blood circulation. Immunosuppression caused by old age, diseases, or prostration, particularly by human immunodeficiency virus infection, increases the risks of reactivation and unusual presentations of TB., Genitourinary TB is not commonly observed in developed countries. The incidence of extrapulmonary TB is approximately 20%–25%, of which genitourinary TB accounts for 4%. Most scrotal TB cases do not involve active pulmonary TB infection. This impedes the definite diagnosis of scrotal TB, subsequently resulting in improper treatment. In this case report, we attempted to increase the awareness among clinicians regarding the diagnosis of TB epididymitis without surgical treatment.
| Case Report|| |
A 65-year-old male patient presented with a 6-month history of the left scrotal swelling. He denied the presence of any systemic disease. He was also initially treated with antibiotics for 2 weeks under the impression of epididymo-orchitis. However, the swelling persisted. On examination, his testes were not swollen, except for the left epididymis, which appeared like a chain of beads. The left epididymis protruded from the scrotal surface with a tumor measuring 1.2 cm × 1.1 cm [Figure 1]. The patient did not feel any tenderness at the site of swelling. All blood chemistry and tumor marker results were unremarkable, except for the positive acid-fast staining of the urine sample. However, the polymerase chain reaction (PCR) was negative. Ultrasonography of the kidneys, bladder, and prostate was within the normal limit. A magnetic resonance imaging (MRI) coronal T2-weighted image revealed nodular thickening and a heterogeneous low signal in the left epididymis. A cystic nodule measuring 1.5 cm was noted at the tail of the epididymis, which showed a low signal intensity (SI) peripheral rim and a high internal SI content in the T2-weighted image [Figure 2]. A postcontrast sagittal image demonstrated peripheral rim enhancement of the nodular lesion, with the involvement of the left tunica vaginalis and the subcutaneous tissue of the scrotum [Figure 3]. The results of MRI imaging were compatible with those of TB epididymitis and cold abscess formation. The patient was scheduled for a biopsy, which revealed chronic caseating granulomatous inflammation [Figure 4]. He was administered anti-TB drugs for 6 months. He did not develop any sequelae and required no surgery [Figure 5]. We followed him for more than 1 year and provided free drugs. He was cured completely. Informed consent was obtained from the patient for reporting this case.
|Figure 2: The coronal T2W image of the cold abscess (↖) in magnetic resonance imaging|
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|Figure 3: The post-contrast sagittal image of the cold abscess (↖) in magnetic resonance imaging|
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|Figure 4: A close-up view of chronic caseating granulomatous inflammation (↖) and Langhans giant cell (↖↖) (H and E, ×200)|
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|Figure 5: A posttreatment image of the scrotum after treatment for more than 1 year|
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| Discussion|| |
Isolated TB epididymitis (ITE) is not easily diagnosed. Thus, many patients in different age groups remain undiagnosed in Taiwan [Table 1]. Some cases require surgical confirmation, which might be attributable to the variable sensitivity and specificity of diagnostic tests such as urine acid-fast staining, sonography, and MRI. However, the typical finding of cold abscess, which is a painless cystic lesion in contrast to hot abscess, were observed in MRI and sonography in the case report by Liu et al. Although they reported that PCR of the urine is useful for the diagnosis of ITE, the PCR results of our patient were negative. The concentration of acid-fast bacteria is different in both urine and sputum. Hence, it is difficult to diagnose genitourinary TB by using acid-fast staining, culture, and PCR. As listed in [Table 1], the sizes of some gross scrotal tumors were too large, making nonsurgical treatment impossible., Moreover, the provisional diagnosis is so vague that surgery is often the final step for treating patients.,
|Table 1: Comparison of the cases of isolated tuberculous epididymitis uncovered in Taiwan|
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ITE should be considered as one of the differential diagnoses for patients presenting with scrotal swelling, irrespective of their age. No definite laboratory tests can provide accurate results, except for biopsy or surgery. Although the cost-effectiveness of tests should be considered, MRI is still a useful tool for making this differential diagnosis. Cold abscess formation is usually found in extrapulmonary TB such as in Pott's disease. Because M. tuberculosis is a fastidious bacterium, the acid-fast staining of urine provides ambiguous results. Moreover, at least six weeks are required to obtain results of TB bacteria culture. ITE can be cured using medications. High clinical suspicion should be maintained to diagnose ITE in a timely manner, especially in patients presenting with painless epididymitis. After the confirmation of ITE, the possibility of TB infection in other sites should be considered. Although the incidence of TB has been decreasing recently in Taiwan, the presence of ITE should not be ignored in clinical practice.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Elliott AM, Luo N, Tembo G, Halwiindi B, Steenbergen G, Machiels L, et al.
Impact of HIV on tuberculosis in Zambia: A cross sectional study. BMJ 1990;301:412-5.
Raviglione MC, Narain JP, Kochi A. HIV-associated tuberculosis in developing countries: Clinical features, diagnosis, and treatment. Bull World Health Organ 1992;70:515-26.
Liu HY, Fu YT, Wu CJ, Sun GH. Tuberculous epididymitis: A case report and literature review. Asian J Androl 2005;7:329-32.
Viswaroop BS, Kekre N, Gopalakrishnan G. Isolated tuberculous epididymitis: A review of forty cases. J Postgrad Med 2005;51:109-11.
] [Full text]
Lee IK, Yang WC, Liu JW. Scrotal tuberculosis in adult patients: A 10-year clinical experience. Am J Trop Med Hyg 2007;77:714-8.
Miu WC, Chung HM, Tsai YC, Luo FJ. Isolated tuberculous epididymitis masquerading as a scrotal tumor. J Microbiol Immunol Infect 2008;41:528-30.
Yu-Hung Lai A, Lu SH, Yu HJ, Kuo YC, Huang CY. Tuberculous epididymitis presenting as huge scrotal tumor. Urology 2009;73:1163.e5-7.
Kho VK, Chan PH. Isolated tuberculous epididymitis presenting as a painless scrotal tumor. J Chin Med Assoc 2012;75:292-5.
Singh JP, Priyadarshi V, Kundu AK, Vijay MK, Bera MK, Pal DK. Genito-urinary tuberculosis revisited – 13 years' experience of a single centre. Indian J Tuberc 2013;60:15-22.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]