Epididymis tuberculosis: Case report and brief review of the literature

The value of histopathologic examination and Xpert (MTB/RIF) assay in diagnosis of cervical lymph node tuberculosis after coarse needle biopsy guided by CEUS: a retrospective analysis of 612 cases

OBJECTIVE

To investigate the value of histopathological examination (HPE) and Xpert Mycobacterium tuberculosis bacilli/rifampicin (MTB/RIF) assay in diagnosis of cervical lymph node tuberculosis (LN TB) after coarse needle biopsy (CNB).

METHODS

We retrospectively analyzed 612 samples obtained from October 2017 to August 2023 from patients suspected cervical LN TB with surgically pathological, microbial culture confirmed, and clinically confirmed cervical lymph node enlargement who received ultrasound-guided CNB assisted by contrast-enhanced ultrasound (CEUS) at our hospital. All specimens were assessed by HPE and the Xpert (MTB/RIF) assay. We analyzed the results to determine the diagnostic value of HPE and Xpert (MTB/RIF) assay in samples taken after CEUS-assisted CNB of LN TB, and to evaluate the safety of CNB.

RESULTS

Based on the comprehensive reference standard established in this study, 532 of 612 patients were diagnosed with cervical LN TB, of which 476 were CNB positive cases, the positive rate of diagnosis was 89.5%。The sensitivity, specificity, positive predictive value, negative and predictive value of HPE were 80.4%, 91.2%, 98.4%, 41.2% respectively, while those of the Xpert MTB/RIF assay were 75.7%, 98.7%, 99.7%, 38.0% respectively. No postoperative complications were noted, and the Clavien-Dindo grade was 2.

CONCLUSION

CEUS-assisted CNB has high diagnostic value and is safe for cervical LN TB. The sensitivity of HPE is slightly higher than that of Xpert (MTB/RIF) assay, and the specificity of Xpert (MTB/RIF) assay is higher than that of HPE, so Xpert (MTB/RIF) assay can correct the cervical lymph node tuberculosis with negative HPE.

Influence of preoperative antituberculosis chemotherapy duration on perioperative complications in patients treated with epididymectomy for epididymal tuberculosis

OBJECTIVES

We aimed to investigate the influence of preoperative antituberculosis chemotherapy duration on perioperative epididymectomy complications in patients with epididymal tuberculosis (ETB).

METHODS

This retrospective study examined patients with ETB between January 1, 2013, and March 31, 2023, who underwent unilateral epididymectomy at our hospital. We selected preoperative antituberculosis chemotherapy duration of 2, 4, and 8 weeks as the cutoffs for this study, to explore whether there are differences in the incidence of intraoperative and 30-day postoperative complications among the patients with different preoperative antituberculosis chemotherapy durations. Intraoperative complications were graded according to the Satava classification, and 30-day postoperative complications were defined according to the Clavien-Dindo classification. The study groups were compared using the unpaired t-test, Wilcoxon rank-sum test, Pearson's chi-square test, or Fisher's exact test, as appropriate.

RESULTS

Overall, 155 patients were included. Statistical analysis revealed that there were no significant differences in the incidence of intraoperative and 30-day postoperative complications between patients with shorter preoperative antituberculosis chemotherapy duration and those with longer preoperative antituberculosis chemotherapy duration.

CONCLUSIONS

In patients with ETB, preoperative antituberculosis chemotherapy duration did not significantly affect the incidence of perioperative complications after epididymectomy.

Two Cases of Testicular Tuberculosis and Review of the Recent Literature

In this review, two cases of testicular tuberculosis (TB) are presented, and another 58 cases published in PubMed between January 1, 2012, and July 31, 2023, are reviewed. Testicular TB remains a disease mainly of the developing world, with one notable exception - the infections caused as a result of Bacillus Calmette-Guérin infusion immunotherapy for bladder cancer. Its clinical course is subacute; however, it might get disseminated and become life-threatening; therefore, prompt diagnosis is very important. The diagnosis can be quite challenging, and testicular tissue is the sample with the highest diagnostic yield, either for microbiological or histopathological diagnosis. On the other hand, its treatment follows the standard guidelines for TB treatment; however, the avoidance of an unnecessary orchiectomy is important.

The challenges in diagnosing isolated epididymal tuberculosis (TB) in an adolescent male: a case report

BACKGROUND

Genitourinary tuberculosis (GUTB) is a common form of extrapulmonary TB (EPTB) in children. An example of GUTB is epididymal TB, which usually presents unspecific chronic clinical manifestations. Definitive diagnosis can be conducted based on bacteriologic confirmation and histopathologic results, but this is challenging due to the paucibacillary nature of EPTB. Therefore, we reported the challenges in diagnosing isolated epididymal TB in an adolescent male.

CASE PRESENTATION

A 16-year-old male presented to respirology clinic with painful swelling of the left scrotum for 3 months before visiting to the hospital. The symptoms were associated with persistent coughing for 2 months, and physical examination of the left scrotum showed swelling accompanied by cardinal signs. A palpable hard mass was found on the left scrotum, with firm borders, measuring 7 × 4 cm. Laboratory examination and tumor markers were within normal limits, although leukocyturia was found, and the urine culture was negative. Genital ultrasound (US) showed epididymitis sinistra with septal hydrocele, while magnetic resonance imaging (MRI) indicated inhomogeneous left epididymitis with bilateral inguinal lymph node enlargement. Although TB evaluation presented a negative purified protein derivative (PPD) test and bacteriologic examination, chest X-ray (CXR) showed perihilar lymphadenopathy. Based on the clinical and radiologic results suggesting TB, the patient was diagnosed with isolated epididymal TB and received quadruple antituberculosis therapy (ATT) for 6 months. After treatment, the left testicle size started to shrink and was equal to the right testicle, also, there were no signs of inflammation, the body weight increased by 5 kg, and cough disappeared. Sperm analysis at the end of treatment indicated teratozoospermia, which was subsequently treated by the urologic surgery department.

CONCLUSIONS

Biopsy and bacteriologic confirmation for TB epididymitis were challenging to perform in the clinical setting. Epididymal TB should be considered in adolescent males with complaints of chronic scrotal swelling and pain. Clinical judgment based on history taking, physical examination, and radiologic features supporting TB features could be helpful in accurate and fast diagnosis for favorable outcome.

The diagnostic challenge of a tuberculous cold abscess of the epididymis: a case report

Background

While genitourinary tuberculosis is a common form of extra-pulmonary tuberculosis, cold abscess of the epididymis is rare with our literature search finding no reports from the West African subregion. Where the index of suspicion is low, diagnosis is missed and unnecessary surgery may be performed on suspicion of a tumour. The aim of this case report is to highlight the diagnostic challenges of this condition in resource-limited settings in order to create awareness within the health community, increase the chance of appropriate diagnosis, thereby facilitating early commencement of treatment so as to avoid needless testicular loss or complications, such as infertility.

Case presentation

A 33-year-old Black African College-educated public service employee resident in Abuja, Nigeria, presented with a one-week history of right scrotal pain and swelling. Genital examination revealed a firm, non-tender epididymal mass which was initially mistaken for a malignancy. There were no constitutional symptoms, and the contralateral testis was normal. The swelling involved only the epididymis. The testis was distinctly palpable but not oedematous. There was some hemi-scrotal oedema. Blood count and urine cultures were normal. Ultrasound scan showed a hypoechogenic, uniformly enlarged epididymis. Testicular tumour markers were negative. However, CT-abdomen showed enlarged para-caval and pelvic nodes which were thought to be due to secondary deposits from a testicular tumour. Scrotal swelling was later found to be due to an abscess of the epididymis at surgery. Histology showed caseous granulomas typical of Mycobacterium tuberculosis. Gene-Xpert, a cartridge-based nucleic acid amplification test, later confirmed that patient had tuberculosis, for which he is being treated.

Conclusion

The differential diagnosis of an epididymal cold abscess from testicular tumour or chronic epididymitis can be challenging. Therefore, a high index of suspicion as well as a complete tuberculosis screen is essential in an apparently healthy patient presenting with a chronic epididymal swelling.

Diagnostic nomogram to differentiate between epididymal tuberculosis and bacterial epididymitis

PURPOSE

We developed and validated a diagnostic nomogram for differentiating epididymal tuberculosis (TB) from bacterial epididymitis.

METHODS

In this retrospective study, we developed a prediction model based on demographics and clinical characteristics. Eligible patients were randomly divided into derivation and validation cohorts (ratio 7:3). Univariate and multivariate regression analyses were used to filter variables and select predictors. Multivariate logistic regression was used to construct the nomogram. Concordance index (C-index), calibration plots, and decision curves analysis (DCA) were used to assess the discrimination, calibration, and clinical usefulness of the nomogram.

RESULTS

We included 147 patients (epididymal TB, 93; bacterial epididymitis, 54). The derivation cohort included 66 patients with epididymal TB and 38 with bacterial epididymitis; the validation cohort included 27 patients with epididymal TB and 16 with bacterial epididymitis. One regression model was built from three differential variables: body mass index, purified protein derivative, and chronic infection. Accordingly, one nomogram was developed. The model had good discrimination and calibration. C-indexes of the derivation and validation cohorts were 0.89 and 0.98 (95% confidence intervals, 0.83-0.95 and 0.94-1.01), respectively. DCA showed that the proposed nomogram was useful for differentiation.

CONCLUSION

The nomogram can differentiate between epididymal TB and bacterial epididymitis.

Surgical management of tuberculous epididymo-orchitis: a retrospective study of 81 cases with long-term follow-up

BACKGROUND

Nowadays, most studies of tuberculous epididymo-orchitis (TBEO) are case reports or small sample cohort series. Our study is aimed to present the largest series of TBEO with our management experiences and long-term follow-up outcomes.

METHODS

Patients diagnosed with TBEO after surgical procedures at Department of Urology, West China Hospital from 2008 to 2019 were included. All clinical features, auxiliary examination results, treatment and histopathological findings were extracted if available.

RESULTS

Eighty-one patients (mean age 50.77 ± 16.1 years) were included. Scrotal swelling (N = 47, 58.0%) and pain (N = 29, 35.8%) were the most common presenting complaint. Pyuria and microscopic hematuria were observed in twenty-two (27.2%) and eight patients (9.9%), respectively. Urine acid fast bacilli cultures were available in 16 patients and all were negative. The mean duration between the onset of symptoms and the definite diagnosis was 6.42 ± 7.0 months. TBEO was considered in 30 (37.0%), tumors in 28 (34.6%) and nonspecific bacterial epididymo-orchitis in 23 (28.4%) patients. All patients received triple therapy of chemotherapy-surgery-pharmacotherapy and definite diagnosis was confirmed through histopathology of surgical specimens. Fifty-five patients were followed up regularly (mean follow-up 82.35 ± 36.6 months). One patient (1.2%) died from liver cirrhosis and no recurrence was observed. Postoperative complications included erectile dysfunction in 4 patients (4.9%), premature ejaculation in 5 patients (6.2%) and sterility in 7 patients (8.6%).

CONCLUSIONS

We recommend patients with advanced TBEO to receive triple therapy of chemotherapy-surgery-pharmacotherapy. Physicians should pay more attention to patients' sexual function and fertility during follow up after treatment completed.

Omental mass combined with indirect inguinal hernia leads to a scrotal mass: A case report

BACKGROUND

Primary omental tumors are uncommon, and omental fibromas account for 2% of these tumors. Due to the low incidence of omental fibromas and the limited relevant literature, it is challenging for clinicians to make an accurate diagnosis of this condition, especially before surgery.

CASE SUMMARY

A 30-year-old man was admitted to the hospital because of a left epididymal mass with vague discomfort for more than 1 mo. A physical examination was performed, and the findings showed that the epididymal mass may have entered the abdominal cavity. Pelvic computed tomography was performed in our hospital and revealed a left inguinal hernia with a mass in the hernial contents, and no masses were found in the left epididymis. A traditional inguinal hernia incision was made. Intraoperative hernia contents were found to be of the greater omentum, and a 2.5 cm-diameter mass was found at the distal end of the greater omentum. The scrotum and epididymis did not exhibit other masses. Then, the mass of the greater omentum was excised. Intraoperative frozen pathological examination suggested a spindle cell tumor. The postoperative pathological examination suggested that the mass was an omental angiofibroma. Postoperatively, the patient recovered well and was discharged. Outpatient re-examinations were performed at 1 mo and half a year after the operation and showed no obvious abnormalities.

CONCLUSION

Due to the low morbidity rate associated with and latent nature of omental tumors, these tumors are difficult to diagnose preoperatively; thorough medical history taking, detailed physical examinations, and necessary imaging auxiliary examinations can help clinicians diagnose and treat these cases.

Nonrenewable energy-environmental and health effects on human capital: empirical evidence from Pakistan

This research work reconnoiters the impact of nonrenewable energy (NRE) consumptions, environmental pollution, and mortality rate on human capital in the presence of economic growth and two common diseases, measles and tuberculosis (TB) in Pakistan. The study uses data from 1995 to 2017 and employs the Autoregressive Distributive Lag (ARDL) model to investigate cointegration and long-run dynamics. Results indicate that nonrenewable energy (oil, coal, and gas) increase air pollution, measles, TB cases, and mortality rate, which affect the human capital in Pakistan. The results of the ARDL confirm the long-run and short-run effects of fossils fuels, air pollution, and diseases on human capital. The results of the Granger Causality confirm the feedback hypothesis between nonrenewable consumption and human capital, between air pollution and human capital. Measles and TB diseases Granger cause human capital. The study recommends some essential points for energy management, environmental management, and diseases control programs to uplift the human capital in Pakistan.