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Jurnal Asosiasi Medis China 75 (2013) 292e295


www.jcma-online.com

Laporan kasus

Terisolasi tuberkulosis epididimitis presentasi sebagai tumor skrotum


menyakitkan
Victor Ka-Siong Kho, Pei-Hui Chan*
Divisi Urologi, Departemen Bedah, Rumah Sakit Memorial Timur Jauh dan Pusat Medis, Banciao, New Taipei City, Taiwan, ROC

Menerima 16 Desember 2012; diterima 21 Mei 2013

Abstrak

Genitourinary tuberculosis, the second most common extrapulmonary tuberculosis (TB), is very difficult to diagnose unless one maintains a
high index of suspicion. Isolated tuberculous epididymitis (ITE), defined as tuberculous epididymitis without clinical evidence of either renal or
prostate involvement, is a rare entity among genitourinary tuberculosis. When diagnosed correctly, ITE can be cured with anti-TB medi-cations.
However, patients with poor response to medical treatment may require surgery. Here, we report a 20-year-old man who presented with a slow-
growing painless scrotal tumor for 2 months, with the initial workup suspicious for a right paratesticular tumor. Surgical resection of the tumor
was therefore scheduled. However, severe pain and redness over the patient’s right hemi-scrotum were noted on the day of surgery. A repeat
scrotal ultrasound was performed that revealed findings suggesting a chronic inflammatory process rather than a malignancy. Frozen section of
the lesion confirmed the ultrasonographic findings, and the pathology established the diagnosis of ITE. The patient remained on anti-TB therapy
postoperatively for 6 months and had an excellent outcome.
Copyright 2012 Elsevier Taiwan LLC and the Chinese Medical Association. All rights reserved.

Keywords: genitourinary tuberculosis; isolated tuberculous epididymitis; orchiectomy; scrotal tumor; scrotal ultrasound

2
1. Introduction system as the three most common extrapulmonary sites.
Evidences from the literature suggest that the infecting
The present incidence and prevalence of tuberculosis (TB) Mycobacterium tuberculosis bacilli reach the kidney through
has not changed significantly for decades due to the emigra- hematogenous spread from the lungs, then spread down the
3
tion of people born in endemic areas of TB, the growing ureter, bladder. and/or prostate. Isolated tuberculous epidid-
population positive for human immunodeficiency virus (HIV) ymitis (ITE), defined as TB epididymitis without clinical and
infection, and the emergence of multidrug resistant strains of laboratory evidence of renal involvement, is usually rare and
Mycobacterium. Despite strict implementation of control 4
difficult to diagnose. Although the typical symptoms and
measures, TB remains one of the leading causes of death imaging signs of epididymal TB have been described by
among notifiable diseases in Taiwan, with an estimated 15,000 5
Madeb et al, the definitive diagnosis of ITE can only be
new cases and approximately 8000 sputum-smear positive confirmed by positive cultures, ZiehleNeelson staining, and/
1 1
cases reported annually. Chang et al reported that the inci- or histopathologic examination. In this report, we present a
dence and mortality rates of TB for aborigines in eastern case of ITE initially presenting as a scrotal tumor that was
Taiwan were 3.1 and 3.2 times higher, respectively, than the diagnosed by histopathologic examination of the surgical
rates for the general population in Taiwan. specimen and managed later with anti-TB medications for 6
Extrapulmonary TB can develop in a variety of locations, months.
with the skeletal, genitourinary tract, and central nervous
2. Case report

* Correspondence author. Dr. Pei-Hui Chan, Division of Urology, Depart- A 20-year-old man, recently discharged from military
ment of Surgery, Far Eastern Memorial Hospital and Medical Center, 21,
Section 2, Nan-Ya South Road, Banciao, New Taipei City 220, Taiwan, ROC. service in eastern Taiwan, came to our clinic due to a slow-
E-mail address: pfchan1952@yahoo.com.tw (P.-H. Chan). growing painless scrotal tumor for the preceding 2 months.

1726-4901/$ - see front matter Copyright 2012 Elsevier Taiwan LLC and the Chinese Medical Association. All rights reserved.
doi:10.1016/j.jcma.2013.04.014
V.K.-S. Kho, P.-H. Chan / Journal of the Chinese Medical Association 75 (2013) 292e295 293

He was healthy previously, without a history of pulmonary


TB, and claimed he had received a bacilli CalmetteeGuerin
vaccination during infancy. Physical examination revealed an
afebrile male with a 5 2-cm non-tender, irregular, nodule in
his right hemi-scrotum. Digital rectal examination revealed a
non-tender, firm, and rubbery prostate. Urinalysis was normal,
without evidence of pyuria, and his complete blood count,
biochemistry, C-reactive protein, alpha-feto protein, and beta-
human chorionic gonadotropin levels were all within normal
limits, with only the lactate-dehydrogenase slightly elevated.
Chest X-ray was clear, and the abdominal computed
tomography scan showed a 5.2-cm heterogenous lesion over
the right paratesticular region involving the epididymis (Fig.
1), with both kidneys normal in appearance (Fig. 2). A scrotal
ultrasound also revealed a 5.2-cm solid heterogenous
paratesticular tumor.
Dengan diagnosis sementara dari tumor paratesticular,
pasien dijadwalkan untuk orchiectomy inguinal kanan tinggi.
Namun, pada hari operasi dijadwalkan, sakit parah dengan
Gambar. 2. Coronal kontras CT scan perut menunjukkan penampilan normal
eritema tercatat atas situs lesi (Gambar. 3). ginjal bilateral.
Sebuah USG skrotum diulang, menunjukkan bahwa lesi
heterogen padat sebelumnya telah menjadi lesi anechoic fokus
dengan kalsifikasi dan gema internal, yang kompatibel dengan dengan sel raksasa Langhan ini, (Gambar. 5A), dan dengan
proses inflamasi kronis. Eksplorasi dari testis kanan dilakukan Ziehl positifeNeelson-bernoda basil (Gambar. 5B). Budaya
melalui sayatan inguinalis. Sekitar 20 mL purulen nanah dengan nanah kemudian juga positif bagi M. tuberculosis. Pasien
jaringan epididimis nekrotik caseous tercatat intraoperatif kemudian diobati dengan kombinasi empat obat (isoniazidþ
(Gambar. 4). bagian beku dari jaringan nekrotik dikirim untuk rifampisin þ etambutol þ pirazinamid) anti-TB selama 2
pemeriksaan dan mengungkapkan peradangan granulomatosa bulan, diikuti oleh tiga jenis obat (isoniazid þ rifampisin
kronis. testis kemudian diawetkan, dan nanah itu dikirim untuk þethambutol) terapi selama 4 bulan. Dia tetap stabil pada
budaya dan Ziehlepewarnaan Neelson. Jaringan nekrotik yang follow-up, dengan kedua testis utuh di dalam skrotum
tersisa dikirim untuk pemeriksaan patologis. urine pasien negatif (Gambar. 6). Ia diuji negatif untuk infeksi HIV selama masa
budaya TB dan Ziehlepewarnaan Neelson. Namun demikian, tindak lanjut di klinik.
pemeriksaan patologis dari jaringan nekrotik menunjukkan
kaseosa reaksi granulomatosa
3. Diskusi

Meskipun kemajuan dalam terapi anti-mikobakteri dan


pelaksanaan yang ketat dari tindakan pengendalian TB
terkenal, prevalensi dan insiden TB tetap tinggi di seluruh
dunia. Epididimis TB, yang menyumbang sekitar 20% dari
6
genitouri-nary TBC, diyakini hasil dari retrograde

Gambar. 1. Kontras computed tomography (CT) scan panggul menunjukkan


(Panah) tumor paratesticular 5,2 cm kanan heterogen, dengan sedikit Gambar. 3. gambar perioperatif dari skrotum kanan bengkak dan eritematosa
penurunan peningkatan dari testis kanan dibandingkan dengan testis kiri. (panah).
294 VK-S. Kho, P.-H. Chan / Jurnal Asosiasi Medis China 75 (2013) 292e295

Gambar. 4. caseous-seperti jaringan nekrotik mencatat intraoperatif.

spread of prostate TB, which is usually secondary to a renal


7
TB. ITE, which is defined as TB epididymitis without clinical Fig. 6. Intact bilateral testis inside the scrotum noted during follow-up at
4
and laboratory evidence of renal involvement, is a rare and clinic.
hard-to-diagnose disease entity. However, some authors have
disputed the existence of true ITE since initial imaging studies
or microscopic examination of the urine may fail to reveal noted in our patient. Typically, ITE occurs unilaterally, but
4 4
a renal lesion. In addition, urine culture can be falsely bilateral involvement has also been reported.
8
negative due to its low sensitivity (as low as 50%). Ross et al Up until now, ITE has shared the same imaging findings as
reported that renal TB or positive urine culture could develop those of other chronic inflammatory processes or testicular
9
during the later course of the disease (ITE). tumor. Commonly used imaging modalities such as scrotal
ITE is usually seen in young adults. In a review of 40 ITE ultrasonography, computed tomography scan, or magnetic
4
patients, Viswaroop et al reported the median age was 32 resonance imaging may show diffuse or focal heterogenous
years (range 21e37 years); our patient falls into this age lesions in the enlarged epididymis, with or without hydrocele,
category. ITE can be either the clinical onset of HIV infection septation, extratesticular calcification, scrotal abscess, or
4,10
or caused by intravesical bacilli CalmetteeGuerin instillation scrotal sinus tract. Therefore, correct preoperative diag-
2
of superficial bladder cancer. Clinically, ITE usually presents nosis of ITE relies on having a high index of suspicion. A
dengan pembengkakan skrotum menyakitkan; Namun, bisa juga
hadir sebagai diagnosis definitif ITE didasarkan pada bahan patologis
massa skrotum menyakitkan, bertindak sebagai petunjuk
pertama dengan kehadiran diperoleh dari aspirasi jarum halus sitologi atau bedah
2 4,11,12
Infeksi TB prostat dan vesikula seminalis. Yg mengganggu reseksi epididimis. Namun, seperti yang kita tahu, denda
aspirasi jarum merupakan kontraindikasi dalam menyajikan
gejala berkemih sering terlihat dalam peradangan akut pasien
dengan tumor skrotum menyakitkan, karena jika keganasan
10,11
epididimis dan testis yang tidak umum di ITE, seperti dulu adalah
Gambar. 5. (A) temuan mikroskopis dari jaringan lunak nekrotik dengan Ziehl positif eNeelson bernoda basil (panah) (asam-cepat noda 400). (B) spesimen
patologis dari jaringan skrotum nekrotik menunjukkan kaseosa peradangan granulomatosa dengan formasi Langhans sel raksasa (panah) dan histiosit epithelioid
(hematoxylin dan eosin, 100).
VK-S. Kho, P.-H. Chan / Jurnal Asosiasi Medis China 75 (2013) 292e295 295

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