An elderly couple suffers from tuberculosis of the reproductive system

Abstract

Introduction

Genitourinary tuberculosis is often secondary to tuberculosis in other parts of the body, and transmits through blood, direct spread, and lymphatic pathway. Female primary infection through sexual intercourse with an active reproductive tuberculosis spouse in an upward transmission way is rare.

Case report

There is an elderly couple with testicular tuberculosis in the male and endometrial tuberculosis in the female. The onset of male patients precedes female patients, and there is no protected sexual intercourse. The possibility of direct sexual transmission and primary infection of genitourinary tuberculosis is considered.

Conclusions

Our findings raise awareness of the transmission route of reproductive system tuberculosis, attach importance to prevention and reduce damage, which is of great significance to reducing infertility and the resulting family problems.

Introduction

Tuberculosis is an infectious disease characterized by granuloma and caseous necrosis caused by Mycobacterium tuberculosis (MTB) infection. MTB can infect organs of multiple systems, and the most common organ is the lung. Tuberculosis is a national class B infectious disease. Extrapulmonary tuberculosis is less infectious, and thus less attention has been paid [1]. In developed countries, the incidence of extrapulmonary tuberculosis is about 20–50 % [2], [3], [4], [5], [6]. Genitourinary tuberculosis accounts for about 15–40 % of extrapulmonary tuberculosis [7]. It is often secondary to tuberculosis in other parts of the body and spreads through blood, direct spread, and lymph. There is a literature report that female primary infection can spread upward through sexual intercourse with the spouse with active reproductive tuberculosis [8], but this mode of transmission is extremely rare [9]. A retrospective cohort analysis indicates that 3–5 % of women with active genital tuberculosis have male partners simultaneously harboring active urogenital tuberculosis [10]. Genital tuberculosis can, albeit rarely, be sexually acquired via tuberculous lesions of the penile mucosa or through the exchange of infected seminal or genital secretions during coitus [11]. Prompt diagnosis is imperative: delayed recognition of genitourinary tuberculosis can culminate in irreversible organ damage—including ureteric strictures, non-functioning kidneys, and infertility—even when appropriate antituberculous therapy is administered [11]. The author treated a male testicular tuberculosis patient and a female endometrial tuberculosis patient. The two patients were an elderly couple, and the possibility of sexual transmission was considered after analysis. Now these two cases are reported to provide a reference for clinical diagnosis and treatment.

Case report

Case 1

The patient, a 79-year-old male, visited the Department of Urology at an external hospital because of “finding scrotal tumor for more than 2 months”. More than two months earlier the patient had noticed a mass in the left scrotum accompanied by dull pain and swelling. Two weeks before presentation the mass had enlarged and the discomfort had intensified. His investigations were reported as follows:

• i.Scrotal and testicular ultrasonography revealed a 31 × 22 mm slightly hypoechoic solid lesion at the lower pole of the left testis.
• ii.Pelvic MRI showed that the left testis volume was increased, and there was a mixed low signal with a size of about 44 * 30 * 44 mm. After enhancement, it was significantly uneven enhancement, and thus the possibility of tumor was considered.
• iii.Erythrocyte sedimentation rate (ESR) was 23 mm/h.
• iv.T-SPOT.TB was positive.

The patient underwent left orchiectomy,and postoperative pathology suggested tuberculosis (Fig. 1). Later, he was transferred to our hospital for further diagnosis and treatment and the white pathological film was sent to our hospital for consultation. After the pathological consultation, he was diagnosed with “testicular tuberculosis” (Fig. 2).

Fig. 1.

Pathological diagnosis: (left testicle) Microscopic examination showed granulomatous inflammation with coagulated necrosis, acid-fast staining (+), consistent with tuberculosis (H&E, × 100).

Fig. 2.

Pathological consultation comments: necrotic granulomatous inflammation of the left testicle, acid-fast staining (+), mycobacterium tuberculosis fluorescence PCR (+), mycobacterium strain identification (-), indicating tuberculous lesions. (A: H&E, × 100; B: Acid-fast staining, × 1000).

Case 2

The patient, a 77-year-old female, visited the Department of Obstetrics and Gynecology at an external hospital because of a “pelvic tumor more than 2 months”. More than two months earlier, she had been admitted to the Department of Respiratory Medicine at the same hospital for “pulmonary infection,” during which pelvic ultrasonography had revealed a pelvic mass. Her investigations were reported as follows:

• i.Pelvic ultrasonography showed an anechoic lesion measuring 41 × 40 × 44 mm within the uterine cavity, with irregular protrusions on the endometrial surface.
• ii.Pelvic CT showed endometrial thickening and a large amount of effusion in the uterine cavity. The possibility of endometrial cancer is considered.
• iii.Erythrocyte sedimentation rate (ESR) was 30 mm/h.
• iv.T-SPOT.TB was negative.

Hysteroscopic curettage was performed twice, and the pathology showed tuberculous lesions (Fig. 3 and Fig. 4). After that, she was transferred to our hospital for further diagnosis and treatment, and the pathological white film was sent to our hospital for consultation. After the pathological consultation, she was diagnosed with “endometrial tuberculosis” (Fig. 5).

Fig. 3.

Pathological diagnosis: (scrape of the uterine cavity) Microscopic examination showed granulomatous inflammation with necrosis, acid-fast staining (small amount +), tending to tuberculosis. (A: H&E, × 200; B: H&E, × 200; C: Acid-fast staining, × 400).

Fig. 4.

Pathological diagnosis: (scrape out uterine cavity) Microscopic examination showed large necrosis and exudation, a small amount of local granuloma and multinucleate giant cell formation, acid-fast staining (-), tuberculosis could not be completely excluded. (H&E, × 50).

Fig. 5.

Pathological consultation comments: necrotizing granulomatous inflammation, acid-fast staining (+), silver hexamine staining (-), Mycobacterium tuberculosis fluorescence PCR (+); Mycobacterium strain identification test results (Mycobacterium tuberculosis), diagnosed as tuberculosis. (A: H&E, × 100; B: Acid-fast staining, × 1000).

The two patients were an elderly couple. We inquired them about their life history and there was still unprotected sexual intercourse in recent years. According to the medical history, testicular tuberculosis was the first in male patients and endometrial tuberculosis was the second in female patients.

Discussion

Male reproductive system tuberculosis is a part of systemic tuberculosis. Due to its close anatomical and physiological relationship with the urinary system, it was previously believed that most of the urinary system tuberculosis was caused by the direct spread through the ejaculatory duct orifice and retrograde infection. However, at present, many pieces of evidence show that male reproductive system tuberculosis is also mainly caused by hematogenous infection [12]. The most common clinical infection sites are epididymis and testis [13], which have a great impact on male sexual function. Therefore, early detection, early diagnosis and early treatment are of great significance to the prognosis. However, testicular tuberculosis shows occasional mild pain and falling feeling in the early stage, and the symptoms are not typical and fail to arouse enough attention. This can result in missed diagnosis, misdiagnosis of other diseases, and even delayed treatment under the influence of traditional concepts. When testicular swelling and pain are aggravated, mass and scrotal rupture occur, and then the damage is relatively serious, and some patients undergo surgical resection to cause disability [14].

Tuberculosis of the female reproductive system is caused by the invasion of Mycobacterium tuberculosis, which infects the female reproductive system, accounting for about 8–10 % of extrapulmonary tuberculosis [15]. When Mycobacterium tuberculosis invades the female body, the first infected part is the fallopian tube, and then to the endometrium, which further develops into chronic inflammation in the reproductive system. The accompanying poor adhesion and weakened transport capacity, or scar tissue proliferation ultimately affects fertility [16]. Fallopian tube tuberculosis is the most common, and endometrial tuberculosis follows, accounting for about 50–80 % of female reproductive system tuberculosis [17]. The combination of hysteroscopy and endometrial biopsy is a reliable basis for the diagnosis of endometrial tuberculosis. Hysterosalpingography (HSG) is the imaging of choice for the evaluation of the anatomy of the female genital tract.HSG is the gold standard to assess the fallopian tube patency [18]. The female patient in this report has undergone hysteroscopic curettage, and the pathology confirmed "endometrial tuberculosis". Moreover, the patient is an elderly female with no fertility needs. Whether the fallopian tubes are patent or not has no impact on the patient's treatment and life, so there is no need to perform HSG.

Reproductive system tuberculosis is mainly caused by blood-borne secondary infection, and there are only a few reports of the possibility of primary infection through sexual transmission. In the case report of Muneyoshi Kimura et al., the spouse of a man diagnosed with epididymal tuberculosis was screened, and her vaginal test was used to culture Mycobacterium tuberculosis. The whole genome sequencing confirmed that the Mycobacterium tuberculosis isolates of both of them were genetically identical [8]. Lan et al. found two different genotypes by sequencing the genome of Mycobacterium tuberculosis in two parts of a patient with pulmonary tuberculosis complicated with testicular tuberculosis, suggesting that the tuberculosis bacilli in the lungs and testis of the patient were infected due to different modes of transmission [19]. Female reproductive system tuberculosis mostly occurs in 20–40-year-old women of childbearing age. Studies have found that the age of onset is delayed, and even postmenopausal women may also suffer from the disease [20]. The direct contact between semen and endometrium may be the cause of genital tuberculosis in this elderly couple. However, due to the failure of whole genome sequencing of pathological specimens, there is a lack of molecular evidence.

Conclusions

Patients with reproductive system tuberculosis often have atypical symptoms in the early stage, and the imaging findings are not specific to non-tuberculosis departments. At the same time, it is easy to cause misdiagnosis and missed diagnosis [13]. Therefore, the understanding of non-tuberculosis specialists on urogenital tuberculosis shall be improved for early diagnosis and timely treatment for these patients. At the same time, for patients with tuberculosis, tuberculosis screening should be carried out on their spouse in time to avoid the spread of tuberculosis through sexual life and reduce the harm to their family.

CRediT authorship contribution statement

Ye Li: Supervision. Liangzhu Zhang: Data curation. Bangmin Huang: Data curation. Heng Mei: Writing – review & editing, Writing – original draft. Xiaoning Liu: Writing – review & editing, Writing – original draft.

Ethical approval

Not applicable.

Consent

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.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.