DELAYED RECOGNITION OF PULMONARY TB AFTER INITIAL MANIFESTATION AS GRANULOMATOUS ORCHITIS

Abstract

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Genital tuberculosis (TB) is an uncommon form of extrapulmonary TB and testicular involvement only accounts for 3% of it. Due to its rarity, testicular TB is often mistaken for other pathologies such as malignancy, and the diagnosis of TB is delayed as we describe in our case report. CASE PRESENTATION: A 79-year-old Guatemalan male with heart failure and coronary artery disease presented with two weeks of left-sided chest pain and dyspnea along with unintentional weight loss and night sweat. Physical exam was notable for diffuse crackles. Chest radiograph found increased bilateral reticulonodular opacities compared to imaging taken five months ago. Computed tomography of the chest showed diffuse tree-in-bud and patchy nodular opacities with mediastinal lymphadenopathy and scattered calcified granulomas. Further history revealed that the patient had a painless testicular mass, which evolved to an abscess requiring treatment with levofloxacin two times. A subsequent orchiectomy was performed, which revealed necrotizing and non-necrotizing granulomas on pathology. Cultures were not sent but acid-fast bacilli (AFB) stain was negative. During the current admission, early morning induced sputum was obtained, and it was positive for AFB stain. The patient was started on anti-TB drugs adjusted to his co-morbidities and discharged after improved symptoms. Sputum culture later grew Mycobacterium tuberculosis (MTB), sensitive to the prescribed agents. DISCUSSION: Our case details a patient with pulmonary TB that first presented as granulomatous orchitis most likely due to MTB. Testicular TB presents with a painful or painless scrotal mass. As other common conditions like malignancy and orchitis are considered first, the diagnosis of TB gets delayed. Testicular cancer was the initial concern in this patient as well since he reported a painless scrotal mass with unintentional weight loss. When he later presented with abscess twice, he was empirically treated with levofloxacin. He also reported chest pressure at that time, which likely improved due to partial treatment with antibiotics. Post-orchiectomy pathology was AFB stain negative, but the findings of necrotizing and non-necrotizing granulomas are highly suspicious for TB. The patient's persistent respiratory complaints along with worsening radiographic findings finally led to the diagnosis of pulmonary TB. CONCLUSIONS: Clinicians must maintain a high index of suspicion for extrapulmonary TB in high-risk individuals as it often presents indolently and without classic systemic symptoms. In those with chronic orchitis, there should be a high suspicion for testicular TB. Should a biopsy be sent, AFB stain and culture need to be ordered. Furthermore, a workup for pulmonary TB should be initiated for appropriate treatment and follow-up. REFERENCE #1: Abbara A, Davidson R. Etiology and management of genitourinary tuberculosis. Nature Review Urology. 2011; 8: 678-688 REFERENCE #2: 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):468-470 REFERENCE #3: World Health Organization. Global tuberculosis Report 2020. 2020. DISCLOSURES: No relevant relationships by Lawrence Benedict, source=Web Response No relevant relationships by Amee Patrawalla, source=Web Response No relevant relationships by Sana Rashid, source=Web Response No relevant relationships by Hyo-bin Um, source=Web Response