13
TUBERCULOUS EPIDIDYMITIS – A CLINICAL CHALLENGE
EPIDIDIMITIS TUBERCULOSA: UN DESAFÍO CLÍNICO
Vitorino Modesto dos Santos1,2*, Lister Arruda Modesto dos Santos3
1 Catholic University of Brasília. Adjunct-professor of
Internal Medicine. Brasília-DF, Brazil
2 Armed Forces Hospital. Brasília-DF, Brazil
3. IAMSPE. General Surgery. São Paulo, SP, Brazil
Abstract
The incidence of extrapulmonary tuberculosis is growing, and it is
estimated that up to 25% of all cases may be extrapulmonary infections,
while the reports of genitourinary sites of this infection remain scarce, in
special with the epididymis involvement. Bilateral epididymal tuberculosis
is an exceeding rare cause of infertility in young, and the GeneXpert
MTB/RIF test is considered a useful tool to the diagnosis conrmation. The
major routes for scrotal tuberculosis are retrograde extensions from the
infections in the prostate or seminal vesicles, and pelvic hematogenous
or lymphatic disseminations. Aiming to emphasize the case study of
isolated epididymal tuberculosis recently published in this Journal, short
additional comments on literature data are presented.
Resumen
La incidencia de tuberculosis extrapulmonar está creciendo y se
estima que hasta el 25% de todos los casos pueden ser infecciones
extrapulmonares, mientras que los informes de sitios genitourinarios
de esta infección siguen siendo escasos, en especial con afectación
del epidídimo. La tuberculosis epididimaria bilateral es una causa
extremadamente rara de infertilidad en jóvenes, y la prueba GeneXpert
MTB/RIF se considera una herramienta útil para la conrmación del
diagnóstico. Las rutas principales de la tuberculosis escrotal son las
extensiones retrógradas de las infecciones en la próstata o las vesículas
seminales y las diseminaciones pélvicas hematógenas o linfáticas. Con
el objetivo de enfatizar el estudio de caso de tuberculosis epididimal
aislada publicado recientemente en esta Revista, se presentan breves
comentarios adicionales sobre los datos de la literatura.
Dear Editor:
The incidence of extrapulmonary TB is growing, but the genitourinary
are uncommon and involve the kidneys, ureters, prostate, seminal
vesicles, testes, and epididymis (1-7). Bilateral epididymal involvement is
rare and may cause infertility in young patients (4,7); and the GeneXpert
MTB/RIF test is considered a good tool to conrm the diagnosis (1,3). One
estimates that 15 to 25% of all cases of TB are extrapulmonary infections,
while the genitourinary sites may correspond up to 20 or to 73% of this
group of cases (5,7). The major routes for testicular TB are retrograde
extensions from the infected prostate and seminal vesicles, as well as
pelvic hematogenous or lymphatic disseminations (1-7). We recently read
the case study by Vilatuña Andrango et al (6), of a 32-year-old BCG
vaccinated male who had a mass with abscess in the testicle following
a local trauma and underwent two drainages and antibiotic therapy
courses without get improvement. He underwent a left orchiectomy and
the nal diagnosis was mycobacterial epididymitis that was successfully
controlled by the specic rst-line antibiotic therapy schedule; the
concomitance of pulmonary TB was ruled out by the imaging and
laboratory results (6). The authors highlighted the genitourinary TB as an
uncommon condition, often with absence of lung involvement, that
must be ruled out in patients from endemic areas (6). Aiming to emphasize
this exceeding rare example of atypical primary TB manifested by
* Corresponding author:
Vitorino Modesto dos Santos
E-mail: vitorinomodesto@gmail.com.
Key words: Epididymitis; Diagnosis; Management; Tuberculosis
Palabras clave: Epididimitis; Diagnóstico; Gestión; Tuberculosis
Forma de citar este artículo: Santos VM,
Santos LAM. Tuberculous epididymitis – A
clinical challenge. Med Vozandes. 2024; 35
(1): 13 - 14
ORCID ID:
Vitorino Modesto dos Santos:
orcid.org/0000-0002-7033-6074
Lister Arruda Modesto dos Santos:
orcid.org/0000-0003-4647-4044
CARTA AL EDITOR
Conflict of interest: The authors have full
freedom of manuscript preparation, and there were no
potential conicts of interest.
Financial disclosure: The authors have no nan-
cial relationships relevant to this article to disclose.
CRediT – Contributor Roles Taxonomy:
Conceptualización, Curación de datos, Análisis formal,
Investigación, Metodología, Visualización, Redacción
– borrador original, Redacción – revisión y edición:
VMDS – LAVMDS.
Este artículo está bajo una
licencia de Creative Com-
mons de tipo Reconocimien-
to – No comercial – Sin obras
derivadas 4.0 International.
DOI: 10.48018/RMVv35i11
Received: 09 – Feb – 2024
Accepted: 30 – Apr – 2024
Publish: 01 – Jul – 2024
Revista Médica Vozandes
Volumen 35, Número 1, 2024
14
isolated epididymitis, short comments on novel literature
data are here presented (1-5,7). A review was done on
pathological and laboratory data of 20 patients who
had guided biopsy of epididymal lesions to investigate
tuberculosis by analysis of acid-fast staining, besides the
specic culture by BACTEC MGIT 960, and GeneXpert
MTB/RIF test (1). Diagnosis of epididymal TB was conrmed
in 15 cases (10 had granulomatous lesions); sensitivity
and specicity of the acid-fast staining, culture, and
GeneXpert MTB/RIF were 26.67% and 100%; 33.33% and
100%; and 86.67% and 100%; respectively (1). The authors
emphasized that the GeneXpert MTB/RIF technique was
the better tool for diagnosis of epididymal TB, besides
its usefulness for rifampicin resistance detection (1). A
41-year-old male had right testicular pain and swelling
for three months and 38°C of temperature suggesting
orchitis, and numerous hypertrophied inguinal lymph
nodes (2). There was neither respiratory nor systemic
manifestations, and with the diagnosis of orchitis he
underwent antibiotic treatment, but persisted with pain
and nocturnal fever. The urine was sterile, there was
leukocytosis and lymphocytosis, BAAR was negative
in urine and semen; the ultrasound images and tumor
markers ruled out malignancy (2). The pulmonary
imaging evaluation did not detect abnormalities
and the resected para testicular nodule allowed to
establish the diagnosis of isolated TB; after receiving
the antituberculosis schedule there was complete
regression of the enlarged lymph nodes (2). The authors
commented on the need to consider the hypothesis of
TB in cases of long course of orchiepididymitis, affecting
individuals with immunosuppression or not (2). The analysis
of 41 samples of core needle biopsy (CNB) performed
in patients with suspicion of epididymal TB from January
2018 to January 2021 and utilizing the GeneXpert MTB/
RIF assay revealed that 37/41 patients had diagnosis
of epididymal TB and four patients had chronic
epididymitis (3). The comparison of sensitivity, specicity,
positive predictive value, negative predictive value,
and area under the curve between histopathological
study and MTB/RIF assay were 86.49% vs 62.16%, 100.00%
vs 100.00%, 100.00% vs 100.00%, 44.44% vs 22.22%, and
0.93 vs 0.81, respectively (3). The authors concluded that
the CNB was adequate for the diagnosis of epididymal
TB. A 37-year-old infertile man had a longstanding left
testicular pain and swelling and a rm tender mass that
was conrmed by ultrasonography in the epididymal
region (4). With the hypothesis of severe epididymitis with
abscess formation, he underwent epididymectomy and
the chronic granulomatous lesions with caseous necrosis
favored the diagnosis of an epidydimal TB, which was
managed by the anti-TB schedule (4). However, within
the rst month of postoperative follow-up he developed
epididymal TB in the right side, successfully controlled
by the completion of specic treatment (4). The authors
stressed the rare occurrence of bilateral epididymal
TB causing infertility. A 32-year-old male had a scrotal
growing, with chronic inammatory process and abscess
involving the spermatic cord and epididymis, without
clinical manifestations or pulmonary images suggestive
of TB, and the diagnosis was isolated epididymal TB (5).
He underwent anti-TB treatment schedule during one
year, because of one month delayed diagnosis causing
the worsening of the epididymis and scrotal sack lesions
(5). The authors stressed that surgical procedures are
the choice in absence of diagnosis or when there are
abscesses, stulas, or extensive epididymis and the testis
involvement (5). A 32-year-old previously healthy man
noticed a mobile scrotal lump evolving to near 1.0 cm
in one month without inguinal lymphadenopathy, or
constitutional symptoms (7). The imaging study revealed
a 19.5 x 16.0 x 26.0 mm nodular thickening next to the left
epididymis head, and a 13 mm thickening in the head and
body of right epididymis (7). The chest X-ray was normal,
and the laboratory routine tests were unremarkable,
but a ne needle aspiration biopsy of the lump showed
granulomas with some Langhans giant cells, besides
the detection of Mycobacterium tuberculosis sensible
to the rifampicin (7). Besides rifampicin, he underwent
isoniazid, ethambutol, and pyrazinamide; and within
the rst month of follow-up, there was a progressive
improvement of scrotal changes (7).
Reports of case studies can enhance the suspicion index
about rare conditions.
EPIDIDIMITIS TUBERCULOSA: UN DESAFÍO CLÍNICO Modesto dos Santos VV, et al.
Referencias
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biopsy in conjunction with GeneXpert MTB/RIF to diagnose epididymal
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2. Jdaini A, El Farhaoui H, Irzi M, Miry N, Bennani A, Barki A. Acute epididymi-
tis revealing isolated testicular tuberculosis: A rare case report. Urol Case
Rep. 2023;49:102456. doi: 10.1016/j.eucr.2023.102456. PMID: 37293368.
3. Liu P, Gu H, Liu Y, Qin Y. Application of core needle biopsy in the diagnosis
of epididymal tuberculosis: a retrospective analysis of 41 cases. Int J Infect
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4. Kim JY, Kim JY, Cho DY, Yu JH. Bilateral epididymal tuberculosis causing
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37426599.
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6. Vilatuña Andrango L, Bustillos Huilca J. Epididimitis como manifestación
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Revista Médica Vozandes
Volumen 35, Número 1, 2024
