An isolated testicular tuberculosis mimicking testicular cancer in north-central Nigeria

Abstract

Testicular tuberculosis (TB) is a rare presentation of extrapulmonary TB. A 46-year-old man presented to our Urology clinic with a painless swelling of the right testis. Examination revealed a hard, non-tender swelling on the inferior pole of the testis that measured 3 x 2 cm. Scrotal ultrasound scan showed a complex mass with multiple hypoechoic lesions at the inferior pole of the right testis with dimension 2.4 x 1.7cm. Laboratory data showed elevated alpha fetoprotein and beta hcG and lymphocytosis. A diagnosis of right testicular cancer was made and the patient had a right transinguinal radical orchidectomy. Histopathology result showed tuberculous granulomata with caseous necrosis surrounded by multinucleated giant cells (Langerhan`s type). The patient subsequently had anti-TB medications. The rarity of this condition makes these findings important to report.

Full text

CASE REPORTS
78
Le Infezioni in Medicina, n. 1, 78-81, 2020
Corresponding author
Christian A. Agbo
E-mail: agbo535@gmail.com
n INTRODUCTION
Worldwide, tuberculosis (TB) continues to be
the most important cause of death from a
single infectious microorganism [1]. TB is caused
by Mycobacterium tuberculosis, a tiny, aerobic,
non-motile, and airborne bacterium that most of-
ten affects the lungs. Tuberculosis is curable and
preventable [2]. Only a very small inoculum of
the bacteria is required to cause infection [3]. The
primary phase of M. tuberculosis infection begins
with inhalation of the mycobacterium and ends
with a T cell-mediated immune response that in-
duces hypersensitivity to the organisms. Genito-
urinary tuberculosis (GUTB) is the second most
common form of extrapulmonary tuberculosis
after lymph node involvement [4]. Genitourinary
tuberculosis is a common form of extrapulmo-
An isolated testicular tuberculosis
mimicking testicular cancer
in north-central Nigeria
Christian A. Agbo1, Mudashiru Lawal2, Dalhatu Jibrin2, Jephthah Esla Enjugu1
1Department of Surgery, Dalhatu Araf Specialist Hospital, Lafia, Nigeria;
2Department of Pathology, Dalhatu Araf Specialist Hospital, Lafia, Nigeria
nary disease, it has been estimated to account for
6.5% of all cases [5]. Genitourinary TB may occur
at any age, but it is more common between the
third and fth decade of life [6, 7]. Genitourinary
tuberculosis (GUTB) usually results from the re-
activation of old, dormant tuberculous diseases
by pathogens of the Mycobacterium tuberculosis
complex [3]. Testicular involvement is usually the
result of local invasion from the epididymis, ret-
rograde seeding from the epididymis, and rarely
by hematogenous spread. Anti-TB chemotherapy
comprising rifampicin, isoniazid, pyrazinamide,
and ethambutol is the mainstay of treatment [7].
Although this is the rst reported case of testicu-
lar TB in our institution, there have been a number
of reports of testicular TB from other institutions
in literature. In other regions within the country,
Orakwe et al and Shugaba et al reported their cas-
es stating need to differentiate testicular TB from
other testicular lesions [8, 9]. In Mozambique,
Namburete et al reported an uncommon testicu-
lar localization of disseminated TB in a HIV pa-
tient [10]. They went ahead to state that there are
Testicular tuberculosis (TB) is a rare presentation of ex-
trapulmonary TB. A 46-year-old man presented to our
Urology clinic with a painless swelling of the right tes-
tis. Examination revealed a hard, non-tender swelling
on the inferior pole of the testis that measured 3 x 2 cm.
Scrotal ultrasound scan showed a complex mass with
multiple hypoechoic lesions at the inferior pole of the
right testis with dimension 2.4x1.7 cm.
Laboratory data showed elevated alpha fetoprotein
and beta hcG and lymphocytosis. A diagnosis of
SUMMARY
right testicular cancer was made and the patient had
a right transinguinal radical orchidectomy. Histo-
pathology result showed tuberculous granulomata
with caseous necrosis surrounded by multinucleat-
ed giant cells (Langerhan’s type).
The patient subsequently had anti-TB medications.
The rarity of this condition makes these ndings im-
portant to report.
Keywords: testis, tuberculosis, cancer.

79An isolated testicular tuberculosis mimicking testicular cancer
no well-dened clinical features suggestive of tes-
ticularTB, which makes the diagnosis difcult to
establish, especially in low-income settings.
We report our rst case of right sided isolated
testicular TB mimicking testicular cancer in a
46-year-old male who had radical orchidectomy
and anti-TB chemotherapy.
n CASE REPORT
A 46-year-old government worker who was mar-
ried with two children presented to our Urology
clinic with a painless swelling of the right testis
of six months duration. There was no preceding
history of trauma to the testis, no weight loss or
respiratory symptoms. He had no contact with a
chronically-coughing adult in the past one year.
He neither smoked cigarettes nor ingested alco-
hol. There was no family history of TB and cancer.
The general examination was normal. Systemic
examination was normal except for the right testis
which revealed a hard, oval shaped, non-tender
mass on the inferior pole of testis that measured
3x2 cm. It was not xed with overlying scrotal
skin, and able to get above the mass. There was
no discharging sinus or scrotal ulceration.
Scrotal ultrasound scan showed a complex mass
with multiple hypoechoic lesions at the inferior
pole of right testis with dimension 2.4x1.7 cm as
seen in Figure 1. The laboratory investigations
showed lymphocytosis and elevated tumour
markers (alpha fetoprotein and beta human cho-
rionic gonadotropin). The rest of blood and urine
examinations were unremarkable. Chest x-ray,
urea, electrolyte, creatinine and liver function
tests were found to be normal.
Sputum microscopy for acid fast bacilli was neg-
ative. Tuberculin skin test and quantiferon done
were negative for tuberculosis. Retroviral screen-
ing and Venereal Disease Research Laboratory
(VDRL) tests were non-reactive. A clinical diag-
nosis of right testicular cancer was made, and the
patient subsequently had a right transinguinal
radical orchidectomy.
Postsurgical histopathology showed tuberculous
granulomata with caseous necrosis surrounded
by multinucleated giant cells (Langerhans type).
Patient was given rifampicin 450 mg/day, isonia-
zid 600 mg/day, pyrazinamide 1500 mg/day and
ethambutol 1200 mg/day for rst 2 months, fol-
lowed by rifampicin and isoniazid for 4 months.
He had a remarkable outcome. The rarity of this
condition makes these ndings important to re-
port.
n DISCUSSION
Worldwide, TB is a leading cause of mortality,
especially in the developing countries which are
TB endemic zones, like Nigeria. Wildbolz was the
rst to introduce the term ‘genitourinary tubercu-
losis’ [3, 11].
Tuberculosis usually begins with inhalation of the
mycobacterium and ends with a T cell-mediated
immune response that induces hypersensitivity
to the organisms. In secondary and disseminated
TB, there is re-infection with mycobacterium or
reactivation of dormant disease, or they progress
directly from the primary mycobacterium lesion
into disseminated disease[9].
The mechanism of spread of tubercle bacilli to the
testis is controversial. It is believed that testicular
involvement is due to local or retrograde spread
of tubercle bacilli from the affected urinary tract
into the prostate via reux, followed by canalicu-
lar spread to the seminal vesicle, deferent duct,
and epididymis [7, 9]. However, TB bacilli may
also gain entry to the testis via the hematogene-
ous and lymphatic spread [9].
The diagnosis of testicular TB is challenging es-
Figure 1 - Ultrasound of the right testis showing com-
plex mass with multiple hypoechoic lesions and reac-
tive hydrocele.

80 C.A. Agbo, M. Lawal, D. Jibrin, et al.
pecially in poor resource setting like ours. There
are no well-dened clinical features suggestive of
testicular TB, which makes the diagnosis difcult
to establish. In our case, the clinical presentation
was only the left sided hard, painful testicular
swelling without any discharging sinus, scrotal
involvement, or urinary tract symptoms. In a re-
ported case from Japan by Sensaki et al. in 2001,
it was shown that the presentation and ndings
of tuberculosis of the testis were similar to those
reported in our case [12]. Shugabaet al. and Gar-
byal et al. reported cases of isolated TB orchitis
presenting with scrotal ulceration [9, 13].
Case reports from Chirindel et al and Abraham
et al showed a similar nding of isolated tes-
ticular TB mimicking testicular cancer [14, 15].
Jumbi et al reported the same in a six-month-
old baby [16].
Although ultrasound of testis is a useful in-
vestigation in the diagnosis of TB orchitis, it is
non-specic and mimics non-specic infection,
inammation, tumour, trauma and infarct [17].
The ultrasound scan nding of our case revealed
a complex mass with multiple hypoechoic lesions
at the inferior pole of right testis with dimension
2.4x1.7 cm. There is associated hydrocele. This is
consistent with nding by Das et al. [7].
Testicular ne needle aspiration cytology (FNAC)
was not done for our patient because of the initial
pre-operative diagnosis of right testicular cancer.
FNAC is not a routine investigation for testicular
cancer [18]. FNAC is usually contra-indicated, in
order to avoid potential involvement of scrotal
wall by testicular neoplasms. If a biopsy is indicat-
ed, it is usually obtained by inguinal exploration
of the testicle. On the other hand, FNAC has a role
in diagnosis of testicular TB thereby preventing
unnecessary orchidectomy [13, 19, 20]. FNAC also
has a role in bilateral testicular neoplasms and le-
sion in a solitary testis. FNAC is less traumatic
and easy to carry out, but it requires considerable
practice in its execution and in the interpretation
of the aspirates [18].
The treatment of testicular TB is a six-month mul-
tidrug regimen including rifampicin, isoniazid,
pyrazinamide, and ethambutol (RIPE) for an in-
itial 2-month period followed by 4-month period
of isoniazid and rifampicin [2]. Our patient was
administered such regimen despite the radical
orchiectomy to prevent further dissemination of
disease.
In conclusion, although it is a rare disease, tuber-
culosis of the testis should be considered as a pos-
sible differential of a testicular cancer. This will
help in prompt diagnosis and early management
thus with good outcome.
Conict of interest
None
n REFERENCES
[1] Hadadi A, Pourmand G, Mehdipour-Aghabagher B.
Unilateral testicular tuberculosis: Case report. Androlo-
gia. 2011; 44 (1), 70-2.
[2] Global tuberculosis report 2018 (WHO/ CDS/
TB/2018.20). Geneva: World Health Organization; 2018
(http://apps.who.int/iris/bitstream/handle/10665/
274453/9789241565646-eng. pdf?ua=1), accessed 18
December 2018.
[3] Zajaczkowski T. Genitourinary tuberculosis: histori-
cal and basic science review: past and present.Cent Eu-
ropean J Urol. 2012; 65 (4), 182-7.
[4] Sharma SK, Mohan A. Extra-pulmonary tuberculo-
sis. Indian J Med Res. 2004; 120 (4), 316-53.
[5] Peto HM, Pratt RH, Harrington TA, et al. Epidemi-
ology of extrapulmonary tuberculosis in the United
States, 1993-2006. Clin infect Dis. 2009; 49 (9), 1350-7.
[6] Merchant S, Bharati A, Merchant N. Tuberculosis of
the genitourinary system-Urinary tract tuberculosis:
Renal tuberculosis-Part I.Indian J Radiol Imaging. 2013;
23 (1), 46-63.
[7] Das A, Batabyal S, Bhattacharjee S, Sengupta A. A
rare case of isolated testicular tuberculosis and review
of literature.J Family Med Prim Care. 2016; 5 (2), 468-70.
[8] Orakwe JC, Okafor PI. Genitourinary tuberculosis
in Nigeria; a review of thirty-one cases. Niger J Clin
Pract. 2005; 8 (2), 69-73.
[9] Shugaba AI, Rabiu AM, Uzokwe C, Matthew RM.
Tuberculosis of the testis: a case report. Clin Med In-
sights Case Rep. 2012; 5, 169-72.
[10] Namburete EI, Di Gennaro F, Jose Maria C, et al.
Uncommon testicular localization of Disseminated TB:
a case report from Mozambique. New Microbiol. 2019;
42 (3), 184-7.
[11] Cho YS, Joo KJ, Kwon CH, Park HJ. Tuberculosis
of testis and prostate that mimicked testicular cancer
in young male soccer player. J Exerc Rehabil. 2013; 9 (3),
389-93.
[12] Senzaki H, Watanabe H, Ishiguro Y. A case of very
rare tuberculosis of the testis. Nihon Hinyokika Gakkai
Zasshi. 2001; 92 (4), 534-7.
[13] Garbyal RS, Gupta P,Kumar S, Anshu Diagnosis of
isolated tuberculous orchitis by ne-needle aspiration
cytology. Diagn Cytopathol. 2006; 34 (10), 698-700.
[14] Chirindel A, Martinez F, Gagliardi JA, Armm M.F.

81An isolated testicular tuberculosis mimicking testicular cancer
Testicular Tuberculosis Without Epididymitis Simulat-
ing Neoplasm.Radiol Case Rep. 2015; 3 (3), 133.
[15] Abraham S, Izaguirre Anariba DE, Dua K, et al. A
case of testicular tuberculosis mimicking malignancy in
a healthy young man.Ther Adv Infect Dis. 2016; 3 (3-4),
110-3.
[16] Jumbi T, Robert Mugo R, Onkunya L, et al. Testic-
ular tuberculosis can mimic a testicular tumor. J Pediatr
Surg Case Reports. 2019; 41, 43-5.
[17] Nepal P, Ojili V, Songmen S, et al. “The Great Mas-
querader”: Sonographic pictoral review of testicular tu-
berculosis and its mimics. J Clin Imaging Sci. 2019; 9, 27.
[18] Pandey A, Nandini N, Jha A, Manjunath G. Fine
needle aspiration cytology and cell block in the diagno-
sis of seminoma testis.J Cytol. 2011; 28 (1), 39-41.
[19] Bannur HB, Malur PR,Dhorigol VM. Tubercular
orchitis in a patient with AIDS: report of a case with
ne needle aspiration diagnosis. Acta Cytol. 2007; 51 (3),
459-60.
[20] Sah SP, Bhadani PP, Regmi R, et al. Fine needle
aspiration cytology of tubercular epididymitis and
epididymo-orchitis. Acta Cytol. 2006; 50 (3), 243-9.