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Case Reports Indian Pediatrics 2000;37: 1013-1016 |
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Unusual Case of Scrotal Swellings |
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Tuberculosis of the male genital tract is extremely uncommon in pediatric population, even in areas known to be endemic for the disease(1). Tubercular epididymo-orchitis is usually noted in an isolated form in adult males following a prolonged latent period; concurrent urinary tract involvement may also be noted(2). We report a 5-year-old child with disseminated tuberculosis whose parents approached us primarily for bilateral testicular swellings.
A five-year-old boy was brought for consultation at a health check-up camp at Salakpur village, district Morang in terai region of far eastern Nepal. The camp was organized as part of the community outreach services rendered by the B.P.Koirala Institute of Health Sciences for people of this region. Parents complained of multiple, bilateral, painless scrotal swellings for last one year. A history of intermittent fever and abdominal distension could also be obtained on further inquiry. There was no history of cough, breath-lessness, pallor, loss of weight or appetite, night sweats, rash, swellings elsewhere, or urinary complaints. There was also no history of vomit-ing, abdominal pain, diarrhea or constipation. The child was BCG vaccinated and there was no history suggestive of tuberculosis in the family or contacts. The boy was grossly malnourished (weight, 10.2 Kg; height, 94.5 cm; both were less than 3rd percentile of NCHS standard). He was afebrile and had mild pallor. Vitals were stable. Multiple, pea sized nodes were palpable bilaterally in cervical, axillary and inguinal areas; few of them were matted and had a doughy feel. Multiple nodular swellings were observed bilaterally in the scrotum. On palpation these swellings were arranged on the posterior aspect of testis in a chain of 3 on right and 2 on the left side, and measured 2 to 4 cm in diameter. These were firm, and non tender except one on the right side that felt cystic. Testes could be perceived separately and appeared normal. Per rectal examination was normal. Abdomen was distended and an ill defined, nodular lump (2.5 ´ 8 cm) was palpable supraumbilically, arranged transversely in the midline. Liver was palpable, 4 cm below costal margin in the right mid-clavicular line and 6 cm below xiphisternum, firm and non tender. Spleen was not palpable. Shifting dullness was present. Chest examination revealed bilateral pleural friction rub and fine basal crepitations. Total leuocyte count was 16,700/mm3 with polymorphs 62%, lymphocytes 33%, monocytes, 3% and eosinophils 2%. Hemoglobin was 8.4 g/dl. Peripheral smear revealed normocytic hypo-chromic anemia with normal platelets; no abnormal cells could be seen. Ultrasonography of the abdomen revealed multiple matted mesenteric lymph nodes arranged transversely just above the umbilicus. Testicular size was increased bilaterally and showed diffuse hypoechogenecity. Entire epididymis was enlarged on the right and only the head was involved on the left side. Enlarged epididymis had a heterogeneous echotexture; cystic echoes were visualized above the right testis. Liver, spleen and kidneys had a normal echotexture. Minimal fluid could be seen in the peritoneal cavity. In an attempt to have the tissue diagnosis, fine needle aspiration cytology was performed from abdominal lump, right and left epididymal swellings and liver. Aspirates from the abdomi-nal lump and left epididymal swelling revealed epitheloid cell granulomas with necrosis. Aspirate from the right epididymal cystic swelling showed straw colored fluid that stained positive for acid fast bacilli. Liver aspirate also exhibited ill defined granulomas. Radiograph of the chest revealed exten- sive bronchopneumonia with bilateral pleural effusion. Tuberculin test was negative. Gastric aspirate and urine were found to be negative for acid fast bacilli. A diagnosis of disseminated tuberculosis was made on the basis of a prolonged history, associated malnutrition, multisystem involve-ment including lymph nodes, mesentery, peritoneum, liver, lungs, pleura, epididymis, and testis and histological demonstration of necrotic granulomas and acid fast bacilli in the epi-didymal fluid. Anti tubercular treatment was started with four drugs for two months followed by two drugs for next ten months (2SHRZ + 10HR). Prednisolone was also administered in a dose of 1.5 mg/kg/day for initial four weeks of therapy. The child was followed up regularly. Fever subsided by second week. Testicular swellings and abdominal lump started regressing by third week of therapy and showed eighty per cent reduction in size after 2 months of starting the regime. Repeated ultrasonography revealed disappearance of pleural, peritoneal and epi-didymal fluids.
Genitourinary tuberculosis accounts for 20 to 73% of all cases of extrapulmonary tuberculosis in the general population but is much rarer in children. It is a form of secondary tubercu- losis with vague symptoms; epididymo-orchitis accounting for 22% of all cases(1). Nearly 90% of cases of all chronic epididymo-orchitis are tuberculous, and the great majority commence insidiously. Tuberculous epididymitis is characterized by non tender, stony hard swelling of the epididymis and may be associated with irregular indurated beading of the vas deferens. Tail of the epididymis is the first to get affected in retrograde tubercular infections; it gets enlarged, nodular and slightly tender. In blood borne infections, the head of the epididymis is involved first(3). In the present case, hematogenous spread appeared much likely due to a short latent period, age of the child, presence of disseminated infection and absence of urinary involvement. Softening of the epididymis, and formation of cold abscess in the posterior aspect of the scrotum is a great diagnostic point in favor of tuberculosis. The abscess may burst out discharging thin pus, later developing a tubercular sinus. In 30% cases, secondary hydro-cele may also be present. Such complications were gratifyingly absent in our case. A negative tuberculin test in the present case could be explained on the basis of concurrent severe malnutrition and presence of extensively disseminated disease. Sonographic appearance of tubercular epi-didymitis in adults has been studied in detail. The heterogeneous and hypoechoeic swelling of the epididymis or the concomitant hypoechoeic lesion of the testis with associated sinus tract or extratesticular calcifications is highly specific and diagnostic for tubercular epididymo-orchitis(4,5). Chlamydial infections should also be considered in the differential diagnosis of granulomatous epididymitis(6). However, it was ruled out by the (i) absence of characteristic histology comprising of minimally destructive periductal and intraepithelial inflammation with active epithelial proliferation; (ii) an insiduous less severe illness; and (iii) presence of AFB in the epididymal fluid. Shafik(7) treated 4 patients of tubercular epididymitis by rifampicin injection alone into the tunica vaginalis sac (once every 4-6 days for 6 months) and compared the results with triple drug oral therapy for the similar duration. Disappearance of epididymal swellings was faster in the group injected with intratunically rifampicin, and none developed scrotal fistula, probably due to a high concentration of the drug reaching the target site. In the present case, since the disease was disseminated, a similar approach was not considered. Moreover, our patient responded well to oral anti-tubercular drugs and steroids. Mbala et al.(8) have also reported tuberculous epididymitis in a three year old boy from Zaire. The present case re-emphasizes the importance of considering tuberculosis in differential diagnosis of testicular and ependymal enlargement in young children in an endemic area, even when there is no history of previous tubercular disease or exposure. Contributors: PG initiated and co-ordinated the case report, designed and executed the case management, and wrote the paper. He is guarantor of the study. KS and RS helped in case analysis, discussion and interpretation of the findings, collection of reference material and writing the report. CS was responsible for outlining the pathological investigations, followed by collection, analysis, interpretation and reporting of pathology findings. RK participated in the execution of the study, particularly designing, data collection and interpretation of the radiological encounters. Funding:
None.
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