A rare case of epididymo-orchitis and scrotal abscess secondary to tuberculosis

A 64-year-old adult male patient originally from Peru with recurrent left loin pain underwent abdominal ultrasonography which revealed an atrophic left kidney and dilated renal pelvis. This was interpreted to either be a complication of chronic renal calculi, or secondary to malignancy. The patient underwent diagnostic investigations to reach a final, unexpected diagnosis.

Abdominal ultrasonography revealed atrophic left kidney with irregular appearance and generalised cortical thickness loss. Renal pelvis was noted to be dilated at 39 mm. (Figure 1)

CT-Urogram and MAG3 scans (Figures 2,3) were also performed to further investigate the non-functioning left kidney, also cystoscopy and left ureteroscopy. Given the above were inconclusive, an anterograde pyelogram was performed which revealed no features of malignancy, however contrast was noted not to progress beyond the pelvi-ureteric junction (PUJ).

The patient later developed a 10-day history of testicular swelling and pain. Despite both oral and IV courses of ciprofloxacin over a 4-week period, and initial testicular ultrasonography reporting epididymo-orchitis, the patient’s symptoms worsened. Repeat testicular ultrasound revealed a scrotal abscess (Figure 4) and he was taken to theatre for exploration.

Histopathological results reported no features of malignancy; however, the findings revealed acute necrotising granulomatous inflammation with positive acid-fast bacilli on Ziehl-Neelsen staining – consistent with tuberculosis.

Background

We herein report a case of a gentleman with an unremarkable past medical history that attended his GP practice on multiple occasions complaining of left loin pain and headaches. He was found to be hypertensive with blood pressure readings as high as 200/105mmHg. Urinalysis revealed microscopic haematuria. Bloods including kidney function tests were within normal limits. He was thus started on antihypertensive medications.

Clinical perspective

The patient had imaging investigations as described above. Following MDT (multidisciplinary team) discussions, it was assumed that delayed drainage into the bladder was possibly secondary to recent passage of calculi, although this was not confirmed on imaging. After this initial presentation where a left chronic nonfunctioning kidney was diagnosed, the patient had normal blood biochemistry and was discharged from urology outpatient clinic as he was asymptomatic.

Imaging perspective

At the time of the initial ultrasound abdomen, as described above the patient had developed a small atrophic kidney with renal pelvis fullness and subsequent CTU performed. At CT the loss of cortical thickness and mild hydronephrosis was confirmed. There were no filling defects to suggest a malignant cause for these features. MAG3 renogram showed that the kidney was non-functioning. This is in line with published literature describing hydronephrosis and parenchymal thinning prior to development of auto-nephrectomy secondary to TB. [1,2]

When the patient presented with scrotal swelling, US initially showed features of epidydimo-orchitis,  with increased vascularity and swelling of the epidydimi and testes. Genitourinary TB affecting the scrotum usually presents secondary to renal TB (as in our case). [3,4] Later, after treatment with antimicrobials, there was no clinical improvement and the patient had another scrotal ultrasound. This showed the development of a scrotal abscess which necessitated exploration.

Outcome

Cultures and swabs reported fully sensitive M.tuberculosis, and he was commenced on anti-tuberculosis triple therapy. Routine follow up since commencing anti-TB therapy showed marked improvement with no further episodes of haematuria or scrotal swelling, and kidney function remains at baseline. 

Take home message

It is acknowledged in the literature that genitourinary TB is a diagnostic challenge due to its rarity and insidious presentation. By raising awareness of its imaging features, a possible diagnosis of tuberculosis can then be suggested and confirmed by laboratory findings.

Written informed patient consent for publication has been obtained.