Isolated testicular tuberculosis mimicking testicular malignancy in a 45-year-old male treated at a tertiary hospital. Case report and literature review

Abstract

Introduction and importance

Tuberculosis is prevalent in African countries especially in sub-Saharan Africa where HIV/AIDS is common. While Testicular tuberculosis is uncommon in the young as well as the elderly, pulmonary tuberculosis is commonly observed in these populations. History, physical examination, scrotal ultrasonography, and fine needle biopsy are important in diagnosis of suspected cases of testicular tuberculosis. Anti-TB therapy is the mainstay of treatment to ensure complete resolution of the lesion. However, in a few cases, orchidectomy is required for both diagnosis and treatment. When treating testicular tuberculosis, it is crucial to do a thorough assessment and investigations to exclude testicular malignancy because tuberculosis can present similarly to a testicular tumor.

Case presentation

We report a rare case of right sided isolated testicular tuberculosis in a 45-year-old male who came with right sided testicular pain and swelling. Blood workups and testicular tumor markers were all normal, scrotal ultrasound reported right heterogenous testicular mass with avascular areas of necrosis and septated fluid collections in the tunica vaginalis with features suggestive of testicular tumor. Right orchiectomy through inguinal approach was done, findings included testicular mass with pus pockets and caseous necrosis occupying the whole testis. Specimen was sent for histopathology which revealed chronic granulomatous inflammation, most likely tuberculosis, and ZN stain confirmed the diagnosis of testicular tuberculosis. In accordance with national TB guidelines, the patient had anti-TB medication for six months, and after 12-months serial follow-up, the patient had completely recovered.

Clinical discussion

Genitourinary tuberculosis is the second most common form of extrapulmonary TB after lymph node tuberculosis. 0.5 % of genitourinary TB involves the testes; On the other hand, isolated testicular TB as presented in our patient, is extremely uncommon, thus may mimic other testicular conditions including testicular tumor, so the diagnosis is challenging. It is important to accurately diagnose testicular TB and differentiate it from other scrotal pathologies especially testicular malignancy as the management is totally different. Testicular tuberculosis is diagnosed by tissue Cytology using FNAC or after an orchidectomy. It requires early, regular, full course combined anti-tuberculosis treatment. The drug treatment method uses three to four anti-tuberculosis drugs for 6–9 months. Surgical treatment is necessary if there is no response to drug treatment or in cases of abscess formation.

Conclusion

Testicular TB is a curable disease, but its diagnosis remains challenging. It is often missed owing to its non- specific symptoms. Thus, testicular TB should be suspected in patients with a notion of contagion or history of tuberculosis. Some of the radiological features are highly suggestive of testicular TB. FNAB could prevent unnecessary orchidectomy. In our case, the presentation was typically mimicking a testicular cancer and the patient underwent trans inguinal orchiectomy, and histology and ZN stain confirmed the diagnosis followed by subsequent six-month anti TB therapy.

Highlights

• •Tuberculosis is prevalent in African countries where HIV is a common disease.
• •ultrasonography, and fine needle biopsy are important in diagnosing testicular tuberculosis.
• •Genitourinary tuberculosis affects the testicles at a rate of 0.5 %.
• •Surgical treatment is necessary if there is no response to drug treatment.
• •Testicular TB is a curable disease, but its diagnosis remains challenging.

1. Inroduction and importance

Tuberculosis can affect many organs in the genitourinary region. It is one of the rare forms of extra-pulmonary involvement. Genital Tuberculosis(TB) is uncommon and testicular TB is even rarer, comprising only 3 % of genital TB [1]. Since isolated testicular involvement is not a common condition, testicular tumor, infarction, and other granulomatous infections should be considered in the differential diagnosis [2].

Males between the ages of 20 and 40 are the most affected, with symptoms including painful or painless scrotal enlargement with or without discharging sinus. Infertility problems may also exist. Due to the higher prevalence of testicular cancer than testicular tuberculosis, a diagnostic conundrum sometimes arises in the senior age group. [1] A fine needle aspiration cytology (FNAC) guided by Ultrasonography(USG) and testicular USG are used to confirm the diagnosis. Testicular biopsies are required, particularly in the elderly since the primary concern in this age group is ruling out testicular cancer. The cornerstone of treatment is anti-TB chemotherapy, which consists of rifampicin, isoniazid, pyrazinamide, and ethambutol. The emergence of drug-resistant tuberculosis and a rapid increase in HIV infection rates exacerbate the dire situation facing the world today [1].

The presentation may co-exist with other scrotal conditions and radiological investigations are important in differentiating benign and malignant conditions of the scrotal regions including testicular tuberculosis. However, MRI has shown superior results in accurate localization and characterization of scrotal lesions as compared to scrotal USG [3]. Regarding our case initial diagnosis was testicular tumor based on clinical evaluation and scrotal USS findings. However, tuberculosis was confirmed by histopathology following orchidectomy.

The presentation for testicular TB varies and can be bilateral or unilateral. Scrotal swelling is the commonest presentation in up to 40 % while acute scrotum and sinus accounts for 10 % and 20 % respectively [4]. In advanced stages, testicular tuberculosis can occasionally manifest as a scrotal fistula [5]. The treatment options depend on initial diagnosis made clinically and on radiological investigation, in our case surgical intervention was the first approach followed by anti TB as per our national TB protocol followed by serial follow up in our department and infectious disease unit until complete recovery.

2. Case presentation

We reviewed a 45 year-old male who presented with right sided testicular pain then swelling for three weeks. The pain was acute in onset, gradually increasing with time. The patient had no history of comorbidities such as diabetes mellitus, or hypertension, he reported no history of genitourinary trauma, no history of pulmonary tuberculosis or TB contact, no history of weight loss, night sweats or fever reported.

On physical examination, the patient's vital signs were within normal ranges, he was conscious, and his general condition was good. The patient's genitalia examination revealed unilateral swelling, a right round, erythematous, movable scrotal lump measuring between 5 and 8 cm in diameter, no discharging sinus, and no swelling of the inguinal lymph nodes.

Laboratory tests: Full blood counts, ESR and biochemistry values were within normal range. Hepatitis serology (HBs Ag, Anti HBs, Anti HCV), VDRL for syphilis (Treponema Pallidum Hemagglutination Assay) and HIV Elisa were all negative, however he had elevated serum ADA (Adenosine deaminase) and ESR while testicular tumor markers were all within normal limits. Scrotal ultrasound reported right heterogenous testicular mass with avascular areas of necrosis and septated fluid collections in tunica vaginalis with features suggestive of testicular tumor.

Right orchiectomy through trans inguinal approach was done. The findings included testicular mass with pus pockets and caseous necrosis occupying the whole testis (Fig. 1, Fig. 2).The specimen was sent for histopathology, which revealed chronic granulomatous inflammation most likely tuberculosis and ZN stain confirmed the diagnosis of testicular tuberculosis (Fig. 3, Fig. 4). The patient was kept on anti- TB medication for 6/12 and had complete recovery on serial follow up of 12 months.

Fig. 1.

Black arrow shows caseous necrosis in testis and pus pockets.

Fig. 2.

Black arrow shows caseous necrosis in testis and pus pockets.

Fig. 3.

H&E Photomicrograph (×100).

Histopathology image(Black arrow) showing chronic testicular granulomatous inflammation.

Fig. 4.

H&E Photomicrograph (×100) showing chronic testicular granulomatous inflammation.(see black arrow).

3. Clinical discussion

Urogenital tuberculosis is the second most common form of extrapulmonary TB, but isolated testicular TB as presented in our patient is extremely uncommon and may mimic other testicular conditions such as testicular infarction, testicular tumor or even testicular torsion rendering the diagnosis challenging, and is often be discovered on pathology examination after orchiectomy [6]. Testicular TB can present with features of infectious, inflammatory, and neoplastic process. While testicular malignancy usually presents as a unilateral lump or painless swelling as an incidental finding [7]. It is important to completely examine the contralateral testis as 0.6 % of patients have a synchronous contralateral testis tumor. Sonographic findings of testicular TB can overlap those of other pathological conditions, so it is important to accurately diagnose testicular TB and distinguish it from other differentials, especially testicular malignancy as the management is totally different [8]. Ultrasound imaging, when combined with a physical examination, provides nearly 100 % sensitivity in the diagnosis of testicular cancer [7]. Testicular cancer is suspected when an ultrasound reveals a hypoechoic, solid, vascularized intratesticular lesion, Further evaluation should include serum tumor markers (AFP, HCG, and LDH) before any intervention, including orchiectomy [9]. Testicular cancer has become more common in recent years, and its significance has grown because of the long-term effects that the disease and its treatment can have on a patient's quality of life. In the last forty years, the incidence of testicular cancer has risen [10]. The diagnosis of testicular TB is confirmed by tissue cytology through FNAC or following orchidectomy. Without a histological result, the diagnosis of testicular TB may not be possible [2]. The epididymis is the commonest extrapulmonary structure to be involved, followed by the seminal vesicles, prostate, testis, and the vas deferens. It is important to have definitive diagnosis in order to have a successful management and preventing unnecessary orchiectomy [11].The main challenge that forces a surgeon to consider unplanned orchiectomies is misdiagnosis and difficulty in diagnosis [12]. A testicular biopsy is a vital diagnostic step. Acid-fast staining (AFS) can be used to identify bacilli, while (Fine needle Aspiration Biopsy (FNAB) and tissue cytology can be used to reveal epithelioid granulomas [13,14]. However, AFS positivity isn't always reliable. Sixty percent of TB cases show positive results [13].

Furthermore, TB orchitis diagnosis is greatly aided by testicular Ultrasonography [14]. The distinctive features of tuberculosis (TB) include diffuse, homogeneous, or heterogeneous, hypoechoic lesions, and nodular enlargements on ultrasonography [14]. Testicular tuberculosis can be distinguished from other conditions such as torsion with the use of Colour Doppler USG.The most common site of genital TB is the epididymis in men, followed by the seminal vesicles, prostate, testis, and the vas deferens [1]. It's debatable how tubercle bacilli spread into the structures of the scrotal sac. It is thought that tubercle bacilli from the affected urinary system travel retrogradely by reflux into the prostate, subsequently followed by canalicular spread to the seminal vesicle, deferent duct, and epididymis, ultimately resulting in TB epididymo-orchitis [15]. However, lymphatic, and hematogenous dissemination are other possible entrance points for TB bacilli. Testicular involvement typically results from either localized or retrograde seeding from the epididymis, with hematogenous spread occurring seldomly [15]. Testicular tuberculosis, like tuberculosis in other structures, requires early, regular, full course combined anti-tuberculosis treatment. The drug treatment method uses three to four anti-tuberculosis drugs for 6–9 months.

Surgical treatment is necessary if there is no response to drug treatment or in cases of abscess formation. When there is active tuberculosis, anti-tuberculosis treatment must be performed before surgical treatment unlike in our case in which the diagnosis of testicular tuberculosis was made post-operatively following right orchiectomy due to suspected testicular tumor [4].

Another indication for right orchidectomy in our patient was poor response to antibiotics for suspected right testicular neoplasm with secondary infection [16]. Although surgical treatment is effective, patients still need regular anti-tuberculosis therapy for 3–6 months after surgery and close follow-up similarly to our case as reported.

4. Conclusion

Testicular TB is a curable disease, but its diagnosis remains challenging. It is often missed owing to its non- specific symptoms. Thus, testicular TB should be suspected in patients with a notion of contagion or history of tuberculosis. Some of the radiological features are highly suggestive of testicular TB. FNAB could prevent unnecessary orchidectomy. In our case, the presentation was typically mimicking testicular cancer and our patient underwent trans-inguinal orchiectomy and histology and ZN stain confirmed the diagnosis followed by subsequent six months anti TB therapy.

Without histological results, the diagnosis of testicular TB may be challenging. In endemic regions where it is not possible to confirm the diagnosis with acid fast staining or culture, the contribution of USG and FNAB is of paramount importance. Testicular TB should always be suspected in the presence of unilateral heterogeneous mass, especially in young men with a history of living or travelling in a region endemic for Tuberculosis.

Disclosure

This report has been published in accord with SCARE criteria [17].

Informed consent and consent for publication

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Ethical approval

This case report study was exempt from ethical approval at our institution, as this paper reports a single case that emerged during normal surgical practice.

Funding

There was no funding concerning this article.

Author contribution

Dr. Sirili Harya: Case report concept, literature review and writing the initial manuscript.

Dr. Charles Nhungo: Literature review, writing the paper, initial corrections and drafting the final manuscript.

Dr. Joseph Martin Lori: Assistant surgeon.

Dr. Amini Alexandre: Patient's Consent form and follow up.

Prof Charles Mkony: Correction and elaboration of the final manuscript.

Dr. Praxeda Ugweyo:Pathological descriptions.

Guarantor

• 1.Prof Charles A. Mkony.
• 2.Dr. Sirili A. Harya.

Research registration number

N/A.

Conflict of interest statement

The authors declare that they have no competing interests.

Data availability

This is not applicable to this article because this is a case report.