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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 8  |  Issue : 2  |  Page : 196-198

Spermatic cord tuberculosis: The great masquerader


Department of Pathology, Kalpana Chawla Government Medical College, Karnal, Haryana, India

Date of Web Publication14-Jun-2019

Correspondence Address:
Sonam Sharma
Department of Pathology, Kalpana Chawla Government Medical College, Karnal, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmy.ijmy_64_19

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  Abstract 


Tuberculosis (TB) is a great mimicker of innumerable diseases and is often overlooked causing diagnostic dilemmas, especially when it occurs at extrapulmonary sites. Spermatic cord TB is a very rare form of genital TB with only a handful of cases documented in the world literature. Here, in this report, an unsuspected case of a spermatic cord TB in a 60-year-old male is described which not only disguised as a tumor but also led to an unneeded surgery as its treatment.

Keywords: Extrapulmonary tuberculosis, orchidectomy, spermatic cord


How to cite this article:
Sharma S. Spermatic cord tuberculosis: The great masquerader. Int J Mycobacteriol 2019;8:196-8

How to cite this URL:
Sharma S. Spermatic cord tuberculosis: The great masquerader. Int J Mycobacteriol [serial online] 2019 [cited 2019 Aug 25];8:196-8. Available from: http://www.ijmyco.org/text.asp?2019/8/2/196/260387




  Introduction Top


Tuberculosis (TB) still remains as one of the major public health concerns, especially in developing countries such as India, China, Pakistan, Nigeria, Bangladesh, and South Africa, which have been declared as TB-endemic zones. To make this scenario more critical, worldwide, the escalation in the incidence of human immunodeficiency virus infection and the emergence of drug-resistant TB further adds to its burden. TB most commonly involves the lungs; however, in 15%–20% of active cases, the infection spreads outside the lungs, causing extrapulmonary TB (EPTB) which occurs more commonly in immunocompromised individuals and can affect any body system.[1],[2],[3] Genitourinary TB is an uncommon type of EPTB and comprises 8%–15% of EPTB. Isolated genital involvement is seen in 28% of genitourinary TB cases and is more common in males. The most common site of genital TB in men is the epididymis, followed by the seminal vesicles, prostate, testis, and vas deferens.[4] TB is usually misdiagnosed in these unusual locations as it can masquerade several other conditions, especially tumors which can, in turn, lead to a diagnostic conundrum and unnecessary aggressive therapeutic interventions. One such experience of an extremely rare case of spermatic cord TB in a 60-year-old male is reported herewith so as to create awareness about this enigmatic entity.


  Case Report Top


A 60-year-old male belonging to a rural background presented with a 6-month history of the left inguinal region swelling, which was initially small, soft, and painful but for the past 2 months, it gradually increased in size, became hard and painless, and was also associated with feeling of heaviness in the left scrotum. There was a history of loss of appetite and weight. However, there was no history of fever, trauma, respiratory symptoms, or genitourinary symptoms. He was a smoker, alcoholic, and farmer by occupation. His medical history for any major disease or prior surgeries as well as family history was non-contributory. On general physical examination, he was of average built and was anemic. Local examination of the left inguinal region swelling revealed a mass measuring 6 cm × 3 cm. It was elliptical, non-tender, fixed, hard, and the overlying skin was normal. His external genitalia as well as all other systemic examinations were within the normal limits. His routine hematological investigations revealed microcytic hypochromic blood picture with normal erythrocyte sedimentation rate (ESR) while various biochemical and microbiological tests and chest X-ray showed no abnormality. On ultrasonography (USG) of the swelling, a heteroechoic lesion measuring 5.5 cm × 2 cm × 0.5 cm was detected in the left spermatic cord. The testis, epididymis, inguinal nodes, and prostate appeared normal on USG. Based on all the clinical and radiological findings, a spermatic cord tumor was suspected. A left high inguinal orchidectomy was performed, and the specimen was sent for histopathological examination. Grossly, a testis measuring 4.5 cm × 3 cm × 2 cm along with the attached spermatic cord measuring 6 cm in length and 2 cm in diameter was received. The external surface of both the testis and spermatic cord was congested [Figure 1]a. On cut-section, the testis and the epididymis showed normal tissue while the spermatic cord was solid and gray-white [Figure 1]b. Microscopic sections examined from testis and epididymis were unremarkable, while the spermatic cord revealed many caseating epithelioid cell granulomas and langhans type of giant cells along with diffuse mononuclear inflammatory cell infiltrate rich in plasma cells and lymphocytes [Figure 2]. Special stains for acid–fast bacilli (AFB) and fungus were negative. Based on these histopathological findings, a final diagnosis of left spermatic cord TB was made. Postoperatively, patient's sputum, urine, and semen sample were tested for AFB. However, they all were negative for it. Mantoux test resulted in 12-mm induration. The patient was started on a 6-month course of antituberculous treatment (ATT) with rifampicin, isoniazid, pyrazinamide, and ethambutol and was discharged from the hospital. He was under regular monthly follow-up, and there was no clinical or laboratory evidence of recurrence or any fresh complaint even after 1 year of treatment.
Figure 1: (a) Resected orchidectomy specimen revealing a thickened spermatic cord. (b) Gray-white cut surface of the spermatic cord and the normal testicular parenchyma

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Figure 2: Microphotography exhibiting (a) Numerous epithelioid cell granulomas, caseous necrosis, Langhans giant cells, and dense inflammatory infiltrate (H and E, ×100). (b) Higher magnification of the epitheliogigantocellular process with the caseous necrosis (H and E, ×400)

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  Discussion Top


Spermatic cord TB is a very rare form of EPTB which was first documented in the world literature by Heckel and De Peyster in 1945.[5] Since then, most of the cases have been reported from Japan followed by a very few in English literature.[6],[7] The current case study presented is unique as it is first to be reported from India. This divergence in the incidence is attributed to the difference in the prevalence of pulmonary TB in each country.[8] The pathogenesis behind the dissemination of tubercle bacilli to the spermatic cord is controversial. It can occur secondary to a dormant or an active pulmonary source although it is seen in <1% of patients with pulmonary infection.[9] In rare cases, contamination by bacillus Calmette–Guérin instillation for bladder cancer has also been implicated.[10] Nevertheless, for the organisms to reach the spermatic cord, the spread either is through the hematogenous route or through the vas deferens or the lymphatics from the genitourinary tract.[6]

On further exploring the existing literature on spermatic cord TB, certain clinicopathological features of this condition draw special attention, which in turn can help in its correct diagnosis and treatment. Clinically, all the age groups can be involved. However, it is usually seen in sexually active males with a genitourinary contamination. Constitutional symptoms such as fever, night sweats, and weight loss are not frequently seen in such patients. The major presenting symptom is a painless or a painful, unilateral or bilateral, inguinal or scrotal mass, the size of which can be variable and may range from half a grain of rice to as large as an infant's head. This mass formation is owing to the tuberculoma formation, which can be of two types, according to the site of occurrence within the cord, i.e., inguinal and intrascrotal. On comparison, the intrascrotal variety is much more common than the inguinal one.[11] Lower urinary tract symptoms such as dysuria and hematuria are usually absent and can occur only when the extra urinary organs are involved.[7],[12] On the other hand, a high index of suspicion and collaboration of all the investigations is required for clinching its definite diagnosis. Once spermatic cord TB is clinically suspected, among all the laboratory tests, the tuberculin skin test, ESR, cytology, urine, as well as blood cultures and semen analysis by polymerase chain reaction play a vital role in its diagnosis.[4],[7],[13] Imaging techniques such as chest X-ray, USG, computed tomography, and magnetic resonance imaging, although not specific, are extremely helpful in its assessment.[14] However, it has been observed that most of the spermatic cord TB cases are often misdiagnosed as hernia, cysts, cord lipoma, hydrocele, funiculocele, spermatocele, hematocele, strangulated hernia or omentum, epididymoorchitis, and tumors of the spermatic cord/testis/epididymis, and most of them are usually a postoperative histopathological surprise after the patients have undergone unwarranted orchidectomy.[11],[15] Therefore, to overcome this problem of belligerent intervention in clinically unsuspected cases of spermatic TB, authors have documented that preoperative frozen section can be helpful, especially in excluding tumors, thereby allowing limited resection of the mass with preservation of the testis and epididymis.[13] Hence, once the diagnosis of spermatic cord TB is confirmed, ATT should be started and continued for 6–9 months to ensure the complete resolution of such a lesion as the overall prognosis of such patients is good.[16]

The current case presented with a painless mass and few constitutional symptoms. It was mistaken as a spermatic cord tumor as the ESR was normal, and the radiological investigations were inconclusive for TB. As spermatic cord TB was not suspected initially, therefore, the tuberculin skin test and the cytology of the swelling were not done. Unfortunately, the patient underwent left high inguinal orchidectomy, and it was only on histopathology that it turned out to be a case of spermatic cord TB. Postoperatively, the Mantoux test was positive and the patient symptoms resolved after 6 months of ATT. An important point to highlight is that the normal ESR prevented the diagnosis toward TB although there was a positive tuberculin skin reaction later. This finding has been well supported by few researchers who have revealed that the individuals who suffered from this condition and exhibited no evidence of discernible involvement of other organs showed not only a strongly positive tuberculin skin test but also a normal ESR. The possible explanation of this might be that a hypersensitivity reaction to tubercle bacilli suppresses multiplication of these bacilli, explaining the strongly positive tuberculin skin test, while the subsequent granuloma formation prevents the spread of infection, allowing the healing process to go which further explains the underlying cause of normal ESR.[8],[16]


  Conclusion Top


Spermatic cord TB is an exceptionally extraordinary entity which should always be kept in mind while dealing with inguinal or intrascrotal swellings, especially in people residing in TB-endemic areas. Further, it is essential that a detailed clinical history and meticulous workup of such patients should be done for timely intervention, suitable treatment, and contact tracing.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Sharma S, Sharma S. Concomitant Madura foot and tuberculosis in a child: A diagnostic dilemma! J Foot Ankle Surg (Asia-Pacific) 2014;1:69-71.  Back to cited text no. 1
    
2.
Bhasin TS, Mannan R, Sharma S, Singh G, Singh G. Extra-pulmonary tuberculosis presenting as established non union tibia shaft fracture. Nat J Lab Med 2016;5:PC1-3.  Back to cited text no. 2
    
3.
Sharma S, Dutta S, Yadav AK, Mandal AK. A rare case of cervical tuberculosis masquerading as carcinoma cervix. Ann Woman Child Health 2016;2:C20-3.  Back to cited text no. 3
    
4.
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;5:468-70.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Heckel NJ, De Peyster FA. Tuberculoma of the spermatic cord. Trans Am Assoc Genitourin Surg 1945;37:193-6.  Back to cited text no. 5
    
6.
Benjelloun A, Elktaibi A, Elharrech Y, Touiti D, Ghoundale O. Tuberculosis of the spermatic cord: Case report. Urol Case Rep 2014;2:176-7.  Back to cited text no. 6
    
7.
Yamasaki S, Sugita O, Tanimura M, Morioka M. Tuberculoma arising in the inguinal portion of the spermatic cord: A case report. Int J Urol 1996;3:514-7.  Back to cited text no. 7
    
8.
Takasaki N, Otake R, Kaneda K, Matsuse I. Primary tuberculosis of spermatic cord: a case report. Nishinihon J Urol 1981;43:1209-11.  Back to cited text no. 8
    
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Gorse GJ, Belshe RB. Male genital tuberculosis: A review of the literature with instructive case reports. Rev Infect Dis 1985;7:511-24.  Back to cited text no. 9
    
10.
Briceño-García EM, Gómez-Pardal A, Alvarez-Bustos G, Artero-Muñoz I, Mar Molinero M, Seara-Valero R, et al. Tuberculous orchiepididymitis after BCG therapy for bladder cancer. J Ultrasound Med 2007;26:977-9.  Back to cited text no. 10
    
11.
Tajika E, Nakamura T, Iwasa Y, Kitagawa M. Tuberculosis of the spermatic cord: A case report. J Clin Urol1984;38:77-9.  Back to cited text no. 11
    
12.
Hayashida S, Hironaka H. Funicular tuberculosis: Report of two cases. Hinyokika Kiyo 1971;17:543-8.  Back to cited text no. 12
    
13.
Al-Meshaan MK, Afif HA. Tuberculoma of the spermatic cord. Med Princ Pract 1999;8:251-4.  Back to cited text no. 13
    
14.
Bomanji JB, Gupta N, Gulati P, Das CJ. Imaging in tuberculosis. Cold Spring Harb Perspect Med 2015;5. pii: a017814.  Back to cited text no. 14
    
15.
Rodríguez D, Olumi AF. Management of spermatic cord tumors: A rare urologic malignancy. Ther Adv Urol 2012;4:325-34.  Back to cited text no. 15
    
16.
Oya M. A case of spermatic tuberculosis. Jpn J Clin Urol 1977;31:559-61.  Back to cited text no. 16
    


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