Scrotal Swelling With an Unexpected Source: Disseminated Pulmonary Tuberculosis With Only Urogenital Symptoms

Abstract Introduction : Genitourinary mycobacterium tuberculosis (MTB), while rare, is the second most common extrapulmonary form of active disease. Initial presentation of genitourinary MTB may be subtle, yet progressive spread along the urinary tract can cause infertility, hydronephrosis, and renal compromise. We present a case of disseminated MTB with pulmonary, lymphatic, adrenal, and urogenital involvement. Case report: A 31-year-old man with no prior medical history presented with progressive scrotal enlargement and dysuria without testicular pain, urethral discharge, fever, night sweats, weight loss, cough, or dyspnea. The patient had immigrated to the United States from Mexico five years prior. Physical examination revealed normal vital signs, no lung abnormalities on auscultation, and an enlarged, painless right scrotum without erythema or discharge. Urinalysis demonstrated sterile pyuria with 6-10 leukocytes. Testicular tumor markers (β human chorionic, alpha fetoprotein, lactate dehydrogenase) were normal. Human immunodeficiency virus, Chlamydia, Gonorrhea, Treponemal, and QuantiFERON gold tests were negative. Erythrocyte sedimentation rate was 43 mmHg and C-reactive protein was 5.1 mg/dl (normal 0.0-0.8 mg/dL). Computed tomography (CT) of the chest, abdomen, and pelvis revealed bilateral lung nodules, destruction and cavitary changes of the right upper lobe, and bronchiectasis, as well as a 2.9 cm right epididymal tail mass, prominent retroperitoneal lymph nodes, and bilateral adrenal nodules. Ultrasonography of the right testicle showed increased extension of the mass through the internal spermatic fascia. Magnetic resonance imaging (MRI) demonstrated renal and prostatic abscesses. Due to an inability to produce sputum for acid-fast bacilli (AFB) testing, the patient underwent bronchoscopy and bronchoalveolar lavage (BAL) of the right upper lobe which was positive for MTB by polymerase chain reaction testing without evidence of rifampin resistance. Pharmacologic treatment was initiated with rifampin 600 mg, isoniazid 300 mg, pyrazinamide 2000 mg, ethambutol 1600mg and B6 daily with symptomatic improvement. Discussion: Extrapulmonary MTB accounts for 15-20% of active disease. The two most common sites of extrapulmonary involvement are the lymph nodes and genitourinary tract. Clinical presentation of genitourinary MTB varies, and delayed diagnosis is common. Our patient had disseminated tuberculosis with pulmonary and urogenital involvement despite absence of pulmonary or systemic symptoms. Clinicians should consider disseminated MTB in patients from endemic areas with genitourinary symptoms and pulmonary imaging abnormalities. Bronchoscopy with BAL may be required for diagnosis if specimens cannot be obtained from the genitourinary tract.