Elmer ress
Case Report
A Case Report of Disseminated Tuberculosis With an
Atypical Presentation
Ratul Sarkara, Pratyay Hasanb, d, Ahmedul Kabirc
Abstract
Here we report a 45-year-old male who presented to us with fever,
loss of appetite, and painless bilateral testicular swellings. His routine
chest X-ray revealed reticulo-nodular opacities in both lung fields.
Ultra-sonogram of both testes revealed multiple fairly large space
occupying lesions in both testes and epididymides. Initially thought
to be a case of testicular tumor with lung metastases, the case later
proved to be a case of chronic disseminated tuberculosis (TB), fol-
lowing fine needle aspiration and cytology of both testicular swell-
ings and lung lesion. His sputum smear also revealed acid fast bacilli
(2+). Interestingly, this patient had fever, loss of appetite, and cough 2
years ago, but remained well without specific anti-tubercular therapy
in the intervening period. This case illustrates that common diseases
can present in confusing and atypical ways. This cloaked appearance
can misguide us to make a wrong diagnosis. Especially in a TB en-
demic zone such as ours, TB should not be excluded from the list of
differential diagnoses, and should be actively searched.
Keywords: Disseminated tuberculosis; Diagnostic dilemma; Atypi-
cal presentation
Introduction
The infamous reputation “captain of all these men of death”,
originally ascribed by Sir William Osler to pneumonia [1],
has later been awarded to tuberculosis (TB) by many includ-
ing clinicians to historians or even novelists [2-4]. TB has
been a scourge of the humankind from time immemorial. Till
date, no other disease in history matches the sheer magnitude
of the misery inflicted by TB on the human race in terms of
morbidity and mortality [5]. TB is caused by bacteria of the
Manuscript accepted for publication June 02, 2016
aBetilaUnion Sub Center, Sadar, Manikganj, Bangladesh
bZinzira
Union Sub Center, Keraniganj, Dhaka, Bangladesh
cDepartment of Medicine, Dhaka Medical College, Dhaka, Bangladesh
dCorresponding Author: Pratyay Hasan, Zinzira Union Sub Center, Kerani-
ganj, Dhaka, Bangladesh. Email: phasanbd@gmail.com
doi: http://dx.doi.org/10.14740/cii40e
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This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License, which permits
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Clin Infect Immun. 2016;1(1):23-26
Mycobacterium tuberculosis complex and usually affects the
lungs, although other organs are involved in up to one-third
of cases [6]. In order of frequency, the extra-pulmonary sites
most commonly involved in TB are the lymph nodes, pleura,
genitourinary tract, bones and joints, meninges, peritoneum
and pericardium [6]. Disseminated TB refers to concurrent in-
volvement of at least two non-contiguous organs of the body
or involvement of the blood and bone marrow by TB process
[7]. Disseminated TB is still uncommon, and unlike the rapid
disseminating form, well known as military TB, chronic me-
tastasizing form is less frequently recognized [8]. In healthy
individuals, the dissemination is contained by a prompt im-
mune response, particularly cell-mediated immunity and inter-
feron gamma pathways, limiting the infection [9]. Therefore,
clinical disseminated disease following primary or reactivation
of established latent TB is more often in relatively or absolute-
ly compromised hosts such as infants, patients with acquired
immune deficiency syndrome (AIDS) or patients with latent
infection placed on a tumor necrosis factor alpha blocker, com-
promising the regular immune surveillance [10-13]. Rarely,
the dissemination occurs in healthy individuals with no known
predisposing condition challenging our clinical suspicion to
consider it as a differential diagnosis, and especially with very
non-specific and atypical features, as is the case presented here.
Case Report
A 45-year-old Bengali male, day laborer, hailing from Satar-
gul, Badda, Dhaka, presented to us with fever, loss of appetite
and bilateral testicular swelling for 3 months. Fever was low-
grade, intermittent associated with evening rise of temperature,
night sweats, and chills and rigor. The highest recorded tem-
perature was 100 °F. He had also lost his appetite during this
course of time. Three months back, he had noticed swelling in
his both testes, which were gradually increasing in size. The
swellings were painless. On query, he mentioned occasional
cough, but no sputum production and hemoptysis. He had no
chest pain, respiratory distress, urinary problem, altered bowel
habit, abdominal distension, abdominal pain, or joint pain, but
he felt unusually fatigued, and at the time of admission, he was
fatigued to such extent that he could not perform any heavy
work. He had lost 15 kg of weight over the last 2 years. In fact,
2 years ago, he had suffered from fever, cough with purulent
sputum production (but no hemoptysis), chest pain and loss
23
Disseminated Tuberculosis
Figure 1. Chest X-ray features changes due to tuberculosis.
of appetite for 3 months. His past records showed that at 2
years before presenting to us, complete blood count (CBC),
sputum smear for acid-fast bacilli (AFB), tuberculin skin test,
bronchoscopy, and repeated chest X-rays were done. Except
erythrocyte sedimentation rate (ESR), which had been 84 mm
in first hour, all other parameters of CBC (done 2 years back
in previous episode) had been normal. Sputum smear exami-
nation with Ziehl-Neelsen (Z-N) stain had revealed no AFB,
and the tuberculin skin test had revealed induration of 5 mm
in 72 h. Chest X-ray done 2 years back had shown ill defined,
nodular and confluent opacities in all the zones of both lung
fields suggestive of bilateral pulmonary TB or secondaries and
also inhomogeneous opacities in both upper zones. Again at
the same time, 2 years back, bronchoscopy also had been done
and bronchial washing had been taken, which had revealed in-
flammatory lesion in the lungs. On clinical and radiological
suspicion of pulmonary TB, he had been given anti-tubercular
drugs, but due to serious hypersensitivity reactions, the drugs
had been stopped after only 2 days. Then he had been pre-
scribed only clarithromycin, and antihistamines. Since then, he
had remained well, until 3 months back, when he again devel-
oped fever and loss of appetite. During this 2-year period, he
had not followed his physicians’ advice and had not taken any
antitubercular drugs. But this time, unlike previous occasion,
he complained of bilateral painless testicular swellings, which
was in fact, one of his main presenting complaints, this time.
He was a non-smoker, non-hypertensive and non-diabetic.
He had no history of contact with TB patient in the past and
24 Articles © The authors | Journal compilation © Clin Infect Immun and Elmer Press Inc™ | www.ciijournal.org
Clin Infect Immun. 2016;1(1):23-26
none of his family members were afflicted with this sort of ill-
ness. Apart from mild anemia, and swellings in the testes and
epididymides, all other general and systemic examination find-
ings were normal. Clinically multiple (3 - 4) swellings were
palpable in both testes and epididymides. The largest one on
right side measured about 7.5 × 6 cm and that on the left meas-
ured about 6 × 3 cm in size. The surface was smooth. They
were firm in consistency, and non-tender. There was no ery-
thema of the overlying skin, nor any local rise of temperature.
CBC done during admission revealed Hb 10.1 g/dL (14 - 16 g/
dL) and ESR 98 mm at first hour (< 20 mm at first hour); other
parameters are within normal limits. Serum bilirubin, serum
glutamic pyruvic transaminase (SGPT), and creatinine were
normal. Serum albumin and prothrombin time were 2.7 g/dL
(3.3 - 5.5 g/dL) and 16.2 s (11 - 14 s), respectively. A chest X-
ray was done and it revealed reticulo-nodular opacities in both
lung fields (Fig. 1), suggestive of bilateral pulmonary TB or
secondaries. Sputum smear with Z-N stain revealed AFB (2+),
which gave us the clue that the lung lesions were due to TB. A
two-dimensional (2D) ultrasonography of both testes was done
2 days after admission and it showed: 1) enlarged right tes-
tis with multiple fairly large, hypoechoic space occupying le-
sions (SOLs), 2) mildly enlarged left testis, with multiple fairly
large, hypoechoic SOLs, 3) grossly enlarged right epididymis,
with multiple hypoechoic, fairly large SOLs, and 4) mildly en-
larged left epididymis with multiple small SOLs.
Subsequently, fine needle aspiration (FNA) of both testic-
ular swellings (epididymis) was done. Smears made from both
epididymal swellings revealed many epithelioid cells, granu-
lomas, giant cells, lymphocytes, histiocytes, small amount of
caseation necrosis and cellular debris. No malignant cells were
seen. All these features were suggestive of granulomatous in-
flammation compatible with TB.
Discussion
TB is an infectious disease caused by bacteria of the M. tuber-
culosis complex. TB infection almost always occurs through
inhalation of aerosolized M. tuberculosis bacilli, which rep-
licate in alveolar macrophages and typically form a Ghon fo-
cus [14]. The mycobacteria remain latent, presumably in lung
granulomas or lymph nodes [15] until an alteration between
the pathogen and the immune cells results in active disease.
Following M. tuberculosis infection, 5-10% of people will de-
velop the active disease while more than 90% of infections
do not result in disease in an immunocompetent individual’s
lifetime [15]. Primary disease occurs soon after the primary
infection in the context of a naive immune system, and the
bacilli multiply and spread [14]. The mycobacteria reach ex-
trapulmonary organs by hematogenous dissemination and can
then spread locally [14]. Post-primary disease occurs long
after primary infection in the context of a sensitized immune
system, either as reactivation of a latent infection or as result of
re-infection with a new strain [9, 14]. Disseminated TB is de-
fined as tuberculous infection involving the blood stream, bone
marrow, liver, or two or more non-contiguous sites, or military
TB [16, 17]. Disseminated TB accounts for 1-2% of all cases
Sarkar et al
of TB infection in immune competent individuals [18]. Our
case presented to us with fever, loss of appetite, and bilateral
testicular swellings. But the fact remains that he had also suf-
fered from fever, cough, chest pain, and loss of appetite 2 years
before this episode. Though there had been no microbiologic
or histopathologic evidence of TB at that time, the clinical and
radiologic features had been suggestive of TB. Though he had
not received specific anti-tubercular therapy, he had received
clarithromycin for some time, which has activity against M.
tuberculosis. It is possible that after 2 years, the disease re-
activated, and spread to involve the genital system. Some re-
searchers have reported that genitourinary tuberculosis (GT)
includes 8-15% of extra-pulmonary tuberculosis [19, 20],
whereas some have mentioned a higher 30-40% of all extra-
pulmonary cases [21]. But there is confusion concerning the
accuracy of these numbers [22]. GT may occur during primary
infection; however, it can expand late after a long latent period,
even 20 - 30 years, following the primary localization [23, 24].
In this patient, the latent period spanned almost of 2 years.
Genital TB in males most commonly involves the epididymis
followed by the prostate [25]. The higher frequency of isolated
epididymal TB lesions in children favors the possibility of he-
matologic spread of infection, whereas adults seem to develop
tuberculous epididymo-orchitis caused by direct spread from
the urinary tract [25, 26]. In 70% of patients, there is a previ-
ous history of TB [27]. Few cases have been reported where tu-
bercular orchitis has been confused with malignancy, creating
diagnostic dilemma such as this case [28-30]. Ultrasonography
features of TB epididymo-orchitis include diffusely enlarged
heterogeneously hypo-echoic, diffusely enlarged homogene-
ously hypo-echoic, and nodular enlarged heterogeneously
hypo-echoic epididymis and testis as seen in this case [31, 32].
However, the sonographic pattern of TB epididymo-orchitis is
non-specific and may be seen with non-TB infection, tumor
or infarction [31, 32]. In the absence of histologic finding, it
may be impossible to differentiate such a swelling from a tes-
ticular tumor [25]. Sensitivity and specificity of FNA biopsy
in diagnosing tuberculous epididymitis has been determined
as 87% and 93%, respectively [33]. Therefore, an FNA biopsy
is very important as the primary examination in patients with
epididymal lesions [33]. The presence of epididymal involve-
ment with a testicular lesion supports an infection rather than
a neoplastic cause [34].
Conclusion and rationale
Disseminated TB is uncommon, and more unthinkable is the
combination of lung and genital lesions, sparing the other or-
gan systems. The chronicity of disease in our case is also re-
markable. Moreover, our case presented with painless bilateral
swellings in the testes and epididymis, and on ultrasonogra-
phy, there were multiple fairly large SOLs in both testes and
epididymides, which were initially confused to be neoplastic
in origin. To add to the confusion, chest X-ray also revealed
reticulo-nodular opacities, mimicking secondaries. But all the
mysteries were unearthed after getting the reports of FNAC
from swellings and sputum smear for AFB. In the end, it turned
out to be a case of disseminated TB. This case again illustrates
Articles © The authors | Journal compilation © Clin Infect Immun and Elmer Press Inc™ | www.ciijournal.org
Clin Infect Immun. 2016;1(1):23-26
the polymorphous presentation of the disease TB. It shows that
common diseases can present in confusing and atypical ways.
This cloaked appearance can misguide us to make a wrong
diagnosis. Especially in a TB endemic zone such as ours, TB
should not be excluded from the list of differential diagnoses,
and should be actively searched.
Competing Interests
The authors declare that they have no competing interests.
Author Contributions
RS and PH contributed to writing, editing, literature review
and overall preparation of this manuscript and in diagnosis of
the patient, and AK contributed greatly in diagnosis and man-
agement of the patient.
Abbreviations
TB: tuberculosis; AIDS: acquired immune deficiency syn-
drome; Z-N: Ziehl-Neelsen stain; WBC: white blood cell;
CBC: complete blood count; ESR: erythrocyte sedimenta-
tion rate; Hb: hemoglobin; SGPT: serum glutamic pyruvic
transaminase; 2D: two-dimensional; SOL: space occupying
lesion; FNA: fine needle aspiration; FNAC: fine needle aspira-
tion and cytology; AFB: acid-fast bacilli
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