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Year : 2009  |  Volume : 46  |  Issue : 3  |  Page : 250--252

Testicular tuberculosis masquerading as testicular tumor

KS Shahi1, G Bhandari2, P Rajput1, A Singh3,  
1 Department of Surgery, U.F.H.T. Medical College, Haldwani (Nainital), India
2 Department of Anesthesiology, U.F.H.T. Medical College, Haldwani (Nainital), India
3 Department of Radiotherapy, U.F.H.T. Medical College, Haldwani (Nainital), India

Correspondence Address:
K S Shahi
Department of Surgery, U.F.H.T. Medical College, Haldwani (Nainital)
India




How to cite this article:
Shahi K S, Bhandari G, Rajput P, Singh A. Testicular tuberculosis masquerading as testicular tumor.Indian J Cancer 2009;46:250-252


How to cite this URL:
Shahi K S, Bhandari G, Rajput P, Singh A. Testicular tuberculosis masquerading as testicular tumor. Indian J Cancer [serial online] 2009 [cited 2019 Dec 16 ];46:250-252
Available from: http://www.indianjcancer.com/text.asp?2009/46/3/250/52968


Full Text

Sir

Tuberculosis infection of scrotal contents is rare and occurs in approximately 7% of the patients with tuberculosis. [1] Its incidence is increasing in association with human immunodeficiency virus (HIV) infection and has an unusual presentation with multidrug-resistant tuberculosis. Prevalence of an associated history of previous tuberculosis infection ranges from 0 to 70% in all cases. [2] Here, we present a case of testicular tuberculosis that had the presentation of a testicular tumor and was diagnosed as tuberculosis after histopathological examination.

A 35-year-old man presented with a history of enlargement of his right testicle and swelling in his upper abdomen, gradually enlarging in size for three months. There was no history of fever, malaise, night sweats, cough or hemoptysis. There was no history of frequency, urgency, burning during micturation or retention of urine. The patient was otherwise healthy on clinical examination. An abdominal examination revealed a nontender, hard, fixed, nodular lump of enlarged lymph nodes in the epigastric region. There was no hepatosplenomegaly and the kidneys were unremarkable. Bowel sounds were normal. On examination of the genitalia, the right testicle was grossly enlarged and was nontender and hard, with a smooth outline. The spermatic cord was normal. The Tralucency test was negative. The opposite testicle was normal. There was no significant inguinal lymphadenopathy. The systemic examination was normal. An ultrasound of the testis reported a well-defined predominantly hypoechoic enlargement of the right testis. The chest X-ray was normal. The computed tomography scan of the abdomen, including pelvis, showed a large heterogeneous mass involving the right testis, approximately 6.4 x 3.2 x 4.3 cm, with minimal hydrocele and multiple lymph nodes, predominantly in the retroperitoneum, left peri-renal, right iliac, and para-aortic regions [Figure 1] and [Figure 2]. Fine needle aspiration cytology (FNAC) from the epigastric mass was nonconclusive. FNAC from the testis was not done as the clinical diagnosis was testicular tumor and it would have upstaged the tumor. The surgery itself was done for confirmation of diagnosis. Mild splenomegaly with multiple focal lesions was also seen. The findings were suggestive of a neoplastic pathology, with possibilities of either lymphoma or leukemia involving the testis or a testicular tumor, with splenic metastasis and lymphadenopathy. His tests were negative for HIV. The lactic acid dehydrogenase (LDH) and beta-human chorionic gonadotropin (HCG) levels were found to be raised. With a clinical diagnosis of testicular tumor, the patient was planned for high inguinal orchidectomy. Per-operatively, the right testis was enlarged in size with loss of testicular architecture. The cut section of the operative specimen showed a rounded, grayish-white, firm growth. Cord structures were normal. Histopathology of the specimen reported multiple epitheloid cell granulomas, caseous necrosis, and Langerhans type giant cells in the testis as well as epididymis. Blood vessels showed congestion. There was infiltration by lymphocytes and monocytes [Figure 3]. The Ziehl-Neelsen (ZN) stain for acid fast bacilli was positive. Postoperatively, the patient was administered antitubercular treatment. He recovered well. His abdominal lymphadenopathy disappeared after three months and an ultrasound, six months after initiation of the treatment, was normal. The patient is doing well after more than one year of follow-up.

Unusual presentations due to new drug-resistant tuberculosis are being seen with increasing frequency in the developing countries. [3],[4] The patients usually have one or the other primary site besides the testis. The different routes of infection may be descending infection from the urinary tract, direct extension from the neighboring organs, early or late hematogenous lymphatic spread, besides primary tuberculosis infection of the urethra. Testicular involvement is mostly due to the local spread from the epididymis, retrograde seeding from the epididymis, and rarely by the hematogenous spread. The hematogenous spread is more common in the epididymis or prostate, due to their rich blood supply. It is often secondary to the pre-existing tuberculosis of the urinary tract, which may be confirmed by the culture of early morning urine specimens. [5] In our case, both the testis and epididymis were involved and produced a firm mass-like testicular tumor. The contour of mass was non-nodular, with no changes in the scrotal skin. The patient had no complaints of low grade fever, weight loss, or longstanding cough, and his LDH and beta-HCG levels were found to be increased.

Serum LDH levels are raised in tuberculous infections. A rise in serum beta-HCG levels has been reported only once. The culture of early morning urine was sterile in three samples taken on three different days. The tunica albugenia was found to be intact during surgery. All these findings indicated a testicular tumor. The diagnosis of testicular tuberculosis was made after a histo-pathological analysis of the operative specimen.

Although rare, tuberculous infection can occur in the testis and present as a testicular tumor with raised tumor markers and abdominal lymph nodes. Therefore, testicular tuberculosis should be considered in differential diagnosis in any patient presenting with testicular swelling and enlarged abdominal lymph nodes. This case highlights the importance of a histopathological examination before starting definitive treatment in such a case.

References

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2Ferrie BG, Rundle JS. Tuberculous epididymo-orchitis: A review of 20 cases. Br J Urol 1983;55:437-9.
3Kumar J, Kumar R. Epididymal tuberculosis with elevated onco-fetal marker. Indian J med Sci 2004;58:254-5.
4Joual A, Rabii R, Guessous H, Benjelloun M, el Mrini M, Benjelloun S. Isolated testicular tuberculosis: a case report. Ann Urol (Paris) 2000;34:192-4.
5Mbala L, Ilunga N, Kadinekene K. A 3-year old boy with tuberculous epididymo-orchitis. Trop Doct 1997;27:50-1.