scispace - formally typeset

Journal ArticleDOI

A 14-year-old boy with Isolated Tuberculous Orchitis

30 Jan 2009-Journal of Nepal Paediatric Society-Vol. 29, Iss: 1, pp 30-32

TL;DR: This case report describes extra pulmonary tuberculosis with exclusively testicular presentation and the confirmatory diagnosis of which was made by FNAC of the testis provides a successful diagnosis, thereby preventing unnecessary orchidectomy.

AbstractThe genitourinary tract is the most common extrapulmonary site affected by tuberculosis. The male genital organs are involved in more than 50% of patients. The epididymis is the commonest structure to be involved, followed by the seminal vesicles, prostate, testis, and the vas deferens. 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 doi:10.3126/jnps.v29i1.1598 J. Nepal Paediatr. Soc. Vol.29(1) p.30-32

Topics: Orchitis (57%), Genitourinary system (50%)

Summary (1 min read)

Jump to: [Introduction][Case Report][Discussion] and [Conclusion]

Introduction

  • The incidence of tuberculosis (TB) is increasing worldwide, with more than 20% of cases exhibiting extrapulmonary manifestations4.
  • 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.
  • 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.
  • Rest of the general examination was normal.
  • Examination revealed 3 x 2 cm extra testicular hard mass and arising from the upper and lower pole of right testis.
  • No dilated blood vessels and calcifi cation were seen.
  • The patient was started on four-drug antitubercular therapy with prednisolone.

Discussion

  • Genitourinary Tuberculosis (TB) accounts for 20- 73% of all cases of extra-pulmonary tuberculosis in the general population and epididymo-orchitis accounts -32-.
  • 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.
  • Tuberculous orchitis may be the fi rst and only presentation of genitourinary TB (GUTB), as in their patient4.
  • 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 miliary8,9,10.

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 manifestations11.

Did you find this useful? Give us your feedback

...read more

Content maybe subject to copyright    Report

-30-
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 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 ori 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, 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
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 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 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 ow is seen in it. No space occupying lesion is
seen within the testis. No dilated blood vessels and
calci cation were seen. Small free uid is seen in tunica
vaginalis.These features were suggestive of chronic
J. Nepal Paediatr. Soc. Vol 29, No. 1

-31-
granulomatous in 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
in 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, ne needle aspiration cytology
of the lesion con 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.

-32-
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 re 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 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 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
con 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.
References
1. Hopewell PC. A clinical view of tuberculosis.
Radiol Clin North Am 1995; 33:641-53.
2. Ross JC. Renal Tuberculosis. Br J Urol 1953;
25:277-315.
3. Elkin M. Urogenital Tuberculosis. In: Pollack
HM, editor. Clinical Urography. WB Saunders:
Philadelphia; 1990. p. 1046.
4. Chattopadhyay A, Bhatnagar V, Agarwala S,
Mitra DK. Genitourinary Tuberculosis in Pediatric
Surgical Practice. J Pediatr Surg 1997; 32:1283-
6.
5. Garbyal RS, Gupta P, Kumar S. Diagnosis of
Isolated Tuberculous Orchitis by Fine-Needle
Aspiration Cytology. Diagn Cytopathol 2006 Oct;
34(10): 698-700.
6. Reeve HR, Weinerth JL, Peterson LJ. Tuberculosis
of Epididymis and Testicle presenting as Hydrocele.
Urology 1974; 4:329-31.
7. Carbal DA, Johnson HW, Coleman GU, Nigro M,
Speert DP. Tuberculous Epididymitis as a cause
of Testicular Pseudomalignancy in two Young
Children. Pediatr Infect Dis 1985; 4:59-62.
8. Kim SH, Pollack HM, Cho KS, Pollack MS, Han
MC. Tuberculous Epididymitis and Epididymo-
Orchitis: Sonographic Findings. J Urol 1993;
150:81-4.
9. Drudi FM, Laghi A, Iannicelli E, Di Nardo R,
Occhiato R, Poggi R, et al . Tubercular Epididymitis
and Orchitis: US Patterns. Eur Radiol 1997;
7:1076-8.
10. Macmillan EW. The Blood Supply of the
Epididymis in Man. Br J Urol 1954; 26:60-71.
11. Mbala L, Ilunga N, kadinekene K. 3-year-Old Boy
with Tuberculous Epididymo-Orchitis. Trop Doct
1997 Jan; 27(1): 50-1.
Citations
More filters

Journal ArticleDOI
TL;DR: A very rare case of left sided isolated testicular TB in a 20-year-old male who was completely cured with 6 months regimen of anti-TB chemotherapy is reported.
Abstract: Testicular tuberculosis (TB) is a rare form of genitourinary TB. It is usually presented as painful or painless testicular swelling with or without scrotal ulceration or discharging sinus. Infertility may occur. Epididymal involvement is usually seen in testicular TB. In most cases, genital TB is associated with TB involvement of kidneys or lower urinary tract. Ultrasound (USG) and USG-guided fine needle aspiration cytology of testicular swelling confirm the diagnosis. Anti-TB chemotherapy is the mainstay of treatment to ensure the complete resolution of the lesion. However, in very few cases, orchidectomy is required for both diagnosis and treatment. Here, we report a very rare case of left sided isolated testicular TB in a 20-year-old male who was completely cured with 6 months regimen of anti-TB chemotherapy.

18 citations


Cites background from "A 14-year-old boy with Isolated Tub..."

  • ...The most common site of genital TB is the epididymis in men, followed by the seminal vesicles, prostate, testis, and the vas deferens.[4]...

    [...]


Journal ArticleDOI
TL;DR: The main objective of this sonographic pictorial review is to discuss the imaging findings, specific differentiating features against each differential and use of ancillary imaging findings whenever available.
Abstract: Testicular tuberculosis (TB) is an uncommon presentation of extrapulmonary TB. Although rare in incidence, it is a great masquerader and should be kept in consideration while assessing focal abnormalities involving the testis. Ultrasound findings alone may be non-specific and mimic other diagnoses including infection, inflammation, tumor, infarct, and trauma. The main objective of this sonographic pictorial review is to discuss the imaging findings, specific differentiating features against each differential and use of ancillary imaging findings whenever available. Concurrent involvement of epididymis, septated hydrocele, scrotal wall edema, and calcification of tunica vaginalis provides strong evidence in an appropriate setting. Available extratesticular ancillary imaging findings must be correlated for correct diagnosis due to non-specific imaging and clinical presentation. Misdiagnosis of scrotal TB may lead to otherwise avoidable epididymo-orchiectomy.

8 citations


Cites background from "A 14-year-old boy with Isolated Tub..."

  • ...Isolated orchitis in the absence of epididymal involvement is rare, however, possible with hematogenous spread.[8,9] Tubercular epididymitis occurs first due to early involvement from retrograde spread of mycobacteria through urinary reflux....

    [...]


Journal ArticleDOI
TL;DR: Two cases of nonhealing genital ulcers in immunocompetent males are seen, which are likely to be cases of extrapulmonary TB.
Abstract: Genital tuberculosis (TB) is a rare, comprising <0.5% cases of extrapulmonary TB. Among cases of genitourinary TB, glandular TB is even rarer. Its a diagnosis of exclusion. Most patients present later in the course of disease due to the associated stigma in view of site of involvement and the hesitancy on the patients's part. We saw two such cases of nonhealing genital ulcers in immunocompetent males.

Cites background from "A 14-year-old boy with Isolated Tub..."

  • ...Other parts involved are seminal vesicles, prostate, testis, and vas deferens in descending order.[4] Glandular TB is a very rare form....

    [...]


Journal ArticleDOI
19 Oct 2021-Cureus
Abstract: The pathogenicity of Mycobacterium tuberculosis (M. tuberculosis) causes it to most commonly manifest within the respiratory system (pulmonary tuberculosis); however, 15% of cases undergo extra-pulmonary spread to various organs. Genitourinary tuberculosis (GUTB) is a rare form of tuberculosis infection which has a propensity to affect the genitourinary tract, primarily affecting the kidneys, epididymis, seminal vesicles and prostate; however, 0.5% of cases result in infection of the testicles. This may present unilaterally or bilaterally with varying atypical presentations, thus misleading physicians in diagnosis. We present a case in a 48-year-old patient admitted to the surgical assessment unit in our hospital presenting with a unilateral painful testicular lesion and scrotal changes. He was admitted nine weeks prior for unexplainable constitutional symptoms however presented again whilst awaiting follow up in an outpatient clinic. Ultrasound guidance and fine-needle aspiration & culture (FNAC) of the lesion resulted in a positive diagnosis for M. tuberculosis. He underwent anti-tuberculous chemotherapy treatment for six months as per clinical guidance with adequate clinical response.

References
More filters

Journal Article
TL;DR: Although tuberculosis (TB) involves the lungs most commonly, nonpulmonary sites of disease are increasingly common and cause systemic symptoms such as fever and weight loss.
Abstract: Although tuberculosis (TB) involves the lungs most commonly, nonpulmonary sites of disease are increasingly common. The modes of presentation of TB and the approach to diagnosis depend on the extent of the disease and the organs that are affected. In addition, TB involving any site commonly causes systemic symptoms such as fever and weight loss. Early and accurate diagnoses depend on recognition of the systemic and local manifestations of TB, the obtaining of appropriate diagnostic tests, and the correct interpretation of results.

83 citations


Journal ArticleDOI
TL;DR: In 6 patients with tuberculous epididymitis the testes were also involved (epididymo-orchitis), and the most notable sonographic findings were an enlarged epididymis, predominantly in the tail portion, and marked heterogeneity of the echo texture of the involved epididysis.
Abstract: The findings at scrotal sonography in 10 patients with tuberculous epididymitis and in 2 with nontuberculous epididymitis are presented. In 6 patients with tuberculous epididymitis the testes were also involved (epididymo-orchitis). The most notable sonographic findings of tuberculous epididymitis were an enlarged epididymis, predominantly in the tail portion, and marked heterogeneity of the echo texture of the involved epididymis. Sonographic findings of associated testicular involvement consisted of a diffusely enlarged hypoechoic testis or ill defined focal intratesticular hypoechoic areas, or an irregular margin between the testis and epididymis. The sonographic findings encountered in patients with tuberculous epididymitis appear to be different from those encountered in nontuberculous epididymitis. Sonography might prove helpful in aiding the clinical distinction between these 2 forms of epididymitis and in demonstrating associated testicular involvement in tuberculous epididymitis.

70 citations


Journal ArticleDOI
TL;DR: The aim of this pictorial essay is to provide an outline of the typical US images of tubercular epididymitis and orchitis.
Abstract: For several decades tuberculosis has been adequately under control in this country, but there has been recent concern that this disease might be coming back to the forefront, due to the influx of immigrants from developing countries where tuberculosis is still rampant. In the years to come we are expecting an increase in cases of genitourinary lesions of tubercular origin, a disease which had practically disappeared in the Western world. The aim of this pictorial essay is to provide an outline of the typical US images of tubercular epididymitis and orchitis.

53 citations


Journal ArticleDOI
TL;DR: The diagnosis of GUTB must be suspected in patients who present with hematuria (gross or otherwise), epididymoorchitis, and patients with long segment or multiple ureteric strictures, in view of the anticipated resurgence in tuberculosis caused by the prevalence of aquired immunodeficiency syndrome.
Abstract: Background: Genitourinary tuberculosis (GUTB) has been reported to account for 20% to 73% of all cases of extrapul-monary tuberculosis in the general population but is much rarer in children. GUTB is a form of secondary tuberculosis with vague symptoms. Surgical intervention is required in a minority of cases. Methods: Nine cases of genitourinary tuberculosis (GUTB) were diagnosed and treated from 1988 to 1995. The age of the patients ranged from 5 to 12 years. There were five boys and four girls. Presenting features were diverse and included gross hematuria in 44% of cases and epididymoorchitis in 22% of cases. Rarer presenting features included acute renal failure, staghorn calculus, and pyonephrosis. Associated or past history of tuberculosis was present in three patients. Conclusive diagnosis was made on the basis of isolation of mycobacterium tuberculosis, histopathology, or cystoscopy in eight patients, whereas one patient was given a therapeutic trial based on clinical manifestations. Results: Response to antitubercular drug therapy was gratifying. Excisional surgery in the form of nephrectomy was needed in one patient, whereas another underwent bilateral ureteric replacement with ileal loops for multiple ureteric strictures. Conclusions: The wide variety of presenting features and pathological lesions that result from GUTB are emphasized. The diagnosis of GUTB must be suspected in patients who present with hematuria (gross or otherwise), epididymoorchitis, and patients with long segment or multiple ureteric strictures. In view of the anticipated resurgence in tuberculosis caused by the prevalence of aquired immunodeficiency syndrome the pediatric urologist must be aware of the pathophysiology and clinical spectrum of this disease.

49 citations


Journal ArticleDOI
01 Mar 1954-BJUI

25 citations


Frequently Asked Questions (1)
Q1. What are the contributions mentioned in the paper "A 14-year-old boy with isolated tuberculous orchitis" ?

The epididymis is the commonest structure to be involved, followed by the seminal vesicles, prostate, testis, and the vas deferens3. This case report describes extra pulmonary tuberculosis with exclusively testicular presentation.