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A 14-year-old boy with Isolated Tuberculous Orchitis
Gurubacharya RL
1
, Gurubacharya SM
2
1
Dr Rajesh Lal Gurubacharya.MBBS. MD Pediatrician. Dr Simmi Misra Gurubacharya. MBBS. MD. Pediatrician.
Address for Correspondence: Dr. Rajesh Lal Gurubacharya, E-mail: rajesh_pul@hotmail.com
Abstract
The genitourinary tract is the most common extrapulmonary site affected by tuberculosis
1
. The male
genital organs are involved in more than 50% of patients
2
. The epididymis is the commonest structure
to be involved, followed by the seminal vesicles, prostate, testis, and the vas deferens
3
. An isolated
tuberculous orchitis without epididymal involvement is rare. This case report describes extra pulmonary
tuberculosis with exclusively testicular presentation. The confirmatory diagnosis of which was made by
FNAC of the testis. It provides a successful diagnosis, thereby preventing unnecessary orchidectomy.
Key words: genitourinary tuberculosis, testis, USG, FNAC
Case Report
Introduction
The incidence of tuberculosis (TB) is increasing
worldwide, with more than 20% of cases exhibiting
extrapulmonary manifestations
4
. The genitourinary
tract is the most common site of extrapulmonary TB.
Testicular TB, although rare, may be the initial location
of infection and may cause infertility. The diagnosis
depends on culture of an organism. However, FNAC is
a useful fi rst choice of investigation
5
. Treatment for TB
remains the combination of three or four anti-TB drugs
for 8 to 10 months. Genitourinary TB remains relatively
rare in Nepal and requires a high index of suspicion to
make the diagnosis.
Case Report
A 14-year-old boy presented with painless
unilateral scrotal enlargement of the right side along
with two extra testicular masses on the same side for
four months duration. No history of fever, cough,
weight loss, anorexia or recent trauma could be
elicited. There was no history of tubercular contact. His
immunization was complete according to EPI schedule.
On physical examination, boy was of average built. His
height, weight and head circumference were within
normal limits. Pulse rate, respiratory rate, temperature
and BP were normal. The hernial orifi ces were intact.
Rest of the general examination was normal. Systemic
examination revealed no abnormalities.
On local examination, testis was found to be
of orange-sized, fi rm to hard in consistency without
any tenderness. Examination revealed 3 x 2 cm extra
testicular hard mass and arising from the upper and
lower pole of right testis. The mass was non-tender and
fi xed to the overlying skin. Transillumination test of the
right scrotal contents was negative. The spermatic cord
was normal with intact sensations. The left testis and
both epididymis were normal. Abdominal examination
was normal and no nodes were palpable in the inguinal
region. No free fl uid was seen on either side.
Hemogram was normal. Urine examination was
normal. Chest X-ray showed left pleural thickening
and right pleural capping. Serum beta-hCG was within
normal limit (normal < 0.5 mIU/ml). To exclude a
diagnosis of tuberculosis, Mantoux test was performed
and was found to be 20x 20 mm at 72 hour. HIV was
also negative.
USG of the scrotum revealed approximately
3.9x3.1x2.5 cm size complex hypoechoic mass noted
in caudal and posterior aspect of the right testis abutting
the tail of the epididymis (Figure 1). The extra testicular
mass shows solid component in cranial aspect (Figure
2) and cystic component in caudal aspect (Figure 3)
with particulated fl uid within it. Another complex,
predominantly cystic area seen in scrotal wall in the
cranial aspect measuring approximately 3.1 cm in size
(Figure 4).However, testis is normal in size, outline with
parenchymal echo texture and echogenecity. Normal
blood fl ow is seen in it. No space occupying lesion is
seen within the testis. No dilated blood vessels and
calcifi cation were seen. Small free fl uid is seen in tunica
vaginalis.These features were suggestive of chronic
J. Nepal Paediatr. Soc. Vol 29, No. 1
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granulomatous infl ammation, probably of tuberculous
etiology. However, the left testis was normal. Abdominal
USG showed normal kidneys.
Fine needle aspiration from the lesion was done
and histopathology revealed a paratesticular lesion with
large areas of necrosis, multiple epitheloid and giant cell
granulomas. The granulomas consisted of epithelioid
cells and Langhan’s type giant cells with lymphocytic
infi ltration consistent with tuberculosis (Figure 5).The
epididymis were found to be uninvolved. However, Z-
N staining and culture-sensitivity were negative.
Fig. 1: Showing Hypoechoic Mass.
Fig. 2: Showing Solid Component in Cranial Aspect.
Fig. 3: Showing Cystic Component in Caudal Aspect.
Fig. 4: Showing Cystic Area in Scrotal Wall.
Ultrasonography of testis helped to arrive at a
diagnosis. However, fi ne needle aspiration cytology
of the lesion confi rmed the diagnosis of testicular
tuberculosis. The patient was started on four-drug anti-
tubercular therapy with prednisolone. At present, 10
months after medication, the recurrence is not found.
The conservative management gave satisfactory result.
The repeat USG of testis and Mantoux were normal.
Discussion
Genitourinary Tuberculosis (TB) accounts for 20-
73% of all cases of extra-pulmonary tuberculosis in the
general population and epididymo-orchitis accounts
Fig. 5: Showing Granuloma with Clusters of Epitheloid
Cells, Lymphocytes.
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for 22% of all cases of genitourinary tuberculosis
4
.
Epididymal involvement was reported in 7% of all
tuberculosis patients
6
.
The route of entry of the tuberculous bacillus
into the scrotal sac structures is a controversial topic.
Most believe that tuberculous epididymo-orchitis is
secondary to direct retrograde spread from the urinary
tract via refl ux. However, tuberculous bacillus can
also gain entry via the hematogeneous and lymphatic
routes
4
.
While it is agreed that tuberculous orchitis is
secondary, this is by no means universal. Tuberculous
orchitis may be the fi rst and only presentation of
genitourinary TB (GUTB),
as in our patient
4
. Carbal et al
7
opined that higher
frequency of isolated lesions in children as in our patient
favoured the possibility of haematological spread of
infection, while adults seem to develop tuberculous
epididymo-orchitis as a result of direct spread from the
urinary tract.
Tuberculous involvement of the epididymides
and testes on USG can be of the following types:
diffusely enlarged, heterogeneously hypoechoic;
diffusely enlarged, homogenously hypoechoic; nodular
enlarged, heterogeneously hypoechoic; or miliary
8,9,10
.
Heterogeneity favours a tuberculous etiology
9
as in our
patient.
Conclusion
The case of a 14-year-old boy with tuberculous
orchitis which shows no lesion in the epididymis
is very rare and ours is the fi rst reported case in the
Nepalese literature. Tuberculous orchitis can be the sole
presentation of genitourinary TB and hence FNAC of
the testis should be performed with suspected testicular
lesion even in the absence of clinical and laboratory
markers of renal involvement. The response to
antitubercular drugs given with prednisolone was rapid.
This case emphasizes the importance of considering
tuberculosis in differential diagnosis of scrotal and
testicular enlargement in young children in an endemic
area despite the absence of systemic, pulmonary and
urinary manifestations
11
.
Acknowledgement
Sincere thanks to Dr. Anjan Shrestha (Pathologist)
for kindly performing FNAC examination and
confi rming the tissue diagnosis of testicular tuberculosis
and Dr. Ram Kumar Ghimire for USG. The author
would like to acknowledge the child and the mother
who kindly consented for publication and the authors
are thankful for granting permission to publish the case
report.
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