- 30-A 14-year-old boy with Isolated Tuberculous Orchitis

The genitourinary tract is the most common extrapulmonary site affected by tuberculosis1. The male genital organs are involved in more than 50% of patients2. The epididymis is the commonest structure to be involved, followed by the seminal vesicles, prostate, testis, and the vas deferens3. An isolated tuberculous orchitis without epididymal involvement is rare. This case report describes extra pulmonary tuberculosis with exclusively testicular presentation. The confirmatory diagnosis of which was made by FNAC of the testis. It provides a successful diagnosis, thereby preventing unnecessary orchidectomy.


Introduction
The incidence of tuberculosis (TB) is increasing worldwide, with more than 20% of cases exhibiting extrapulmonary manifestations 4 .The genitourinary tract is the most common site of extrapulmonary TB.Testicular TB, although rare, may be the initial location of infection and may cause infertility.The diagnosis depends on culture of an organism.However, FNAC is a useful fi rst choice of investigation 5 .Treatment for TB remains the combination of three or four anti-TB drugs for 8 to 10 months.Genitourinary TB remains relatively rare in Nepal and requires a high index of suspicion to make the diagnosis.

Case Report
A 14-year-old boy presented with painless unilateral scrotal enlargement of the right side along with two extra testicular masses on the same side for four months duration.No history of fever, cough, weight loss, anorexia or recent trauma could be elicited.There was no history of tubercular contact.His immunization was complete according to EPI schedule.On physical examination, boy was of average built.His height, weight and head circumference were within normal limits.Pulse rate, respiratory rate, temperature and BP were normal.The hernial orifi ces were intact.Rest of the general examination was normal.Systemic examination revealed no abnormalities.
On local examination, testis was found to be of orange-sized, fi rm to hard in consistency without any tenderness.Examination revealed 3 x 2 cm extra testicular hard mass and arising from the upper and lower pole of right testis.The mass was non-tender and fi xed to the overlying skin.Transillumination test of the right scrotal contents was negative.The spermatic cord was normal with intact sensations.The left testis and both epididymis were normal.Abdominal examination was normal and no nodes were palpable in the inguinal region.No free fl uid was seen on either side.
Hemogram was normal.Urine examination was normal.Chest X-ray showed left pleural thickening and right pleural capping.Serum beta-hCG was within normal limit (normal < 0.5 mIU/ml).To exclude a diagnosis of tuberculosis, Mantoux test was performed and was found to be 20x 20 mm at 72 hour.HIV was also negative.USG of the scrotum revealed approximately 3.9x3.1x2.5 cm size complex hypoechoic mass noted in caudal and posterior aspect of the right testis abutting the tail of the epididymis (Figure 1).The extra testicular mass shows solid component in cranial aspect (Figure 2) and cystic component in caudal aspect (Figure 3) with particulated fl uid within it.Another complex, predominantly cystic area seen in scrotal wall in the cranial aspect measuring approximately 3.1 cm in size (Figure 4).However, testis is normal in size, outline with parenchymal echo texture and echogenecity.Normal blood fl ow is seen in it.No space occupying lesion is seen within the testis.No dilated blood vessels and calcifi cation were seen.Small free fl uid is seen in tunica vaginalis.These features were suggestive of chronic granulomatous infl ammation, probably of tuberculous etiology.However, the left testis was normal.Abdominal USG showed normal kidneys.
Fine needle aspiration from the lesion was done and histopathology revealed a paratesticular lesion with large areas of necrosis, multiple epitheloid and giant cell granulomas.The granulomas consisted of epithelioid cells and Langhan's type giant cells with lymphocytic infi ltration consistent with tuberculosis (Figure 5).The epididymis were found to be uninvolved.However, Z-N staining and culture-sensitivity were negative.Ultrasonography of testis helped to arrive at a diagnosis.However, fi ne needle aspiration cytology of the lesion confi rmed the diagnosis of testicular tuberculosis.The patient was started on four-drug antitubercular therapy with prednisolone.At present, 10 months after medication, the recurrence is not found.The conservative management gave satisfactory result.The repeat USG of testis and Mantoux were normal.

Discussion
Genitourinary Tuberculosis (TB) accounts for 20-73% of all cases of extra-pulmonary tuberculosis in the general population and epididymo-orchitis accounts for 22% of all cases of genitourinary tuberculosis 4 .
Epididymal involvement was reported in 7% of all tuberculosis patients 6 .
The route of entry of the tuberculous bacillus into the scrotal sac structures is a controversial topic.Most believe that tuberculous epididymo-orchitis is secondary to direct retrograde spread from the urinary tract via refl ux.However, tuberculous bacillus can also gain entry via the hematogeneous and lymphatic routes 4 .
While it is agreed that tuberculous orchitis is secondary, this is by no means universal.Tuberculous orchitis may be the fi rst and only presentation of genitourinary TB (GUTB), as in our patient 4 .Carbal et al 7 opined that higher frequency of isolated lesions in children as in our patient favoured the possibility of haematological spread of infection, while adults seem to develop tuberculous epididymo-orchitis as a result of direct spread from the urinary tract.

Conclusion
The case of a 14-year-old boy with tuberculous orchitis which shows no lesion in the epididymis is very rare and ours is the fi rst reported case in the Nepalese literature.Tuberculous orchitis can be the sole presentation of genitourinary TB and hence FNAC of the testis should be performed with suspected testicular lesion even in the absence of clinical and laboratory markers of renal involvement.The response to antitubercular drugs given with prednisolone was rapid.This case emphasizes the importance of considering tuberculosis in differential diagnosis of scrotal and testicular enlargement in young children in an endemic area despite the absence of systemic, pulmonary and urinary manifestations 11 .