Genital Tuberculosis Masquerading as Sexually Transmitted Genital Ulcer Disease

Extrapulmonary tuberculosis (EPTB) makes up 20%–30% of all tuberculosis cases, with genitourinary involvement representing 28%–30% of EPTB presentations. Cutaneous tuberculosis accounts for about 2% of EPTB cases [1]. Primary penile tuberculosis, isolated to the glans penis, is exceedingly rare, with fewer than 50 documented cases since 1912 [2]. We present a case of primary tuberculosis of the glans penis, initially misdiagnosed as sexually transmitted genital ulcer disease. A 27-year-old immunocompetent male in a monogamous relationship was evaluated for a one-year history of recurrent genital ulcers on the glans penis. The lesions initially appeared as erythematous papules, which progressed to ulceration over 3–4 weeks and subsequently resolved spontaneously, accompanied by the development of new lesions. The patient denied weight loss, night sweats, chronic cough, known tuberculosis exposure, trauma, or high-risk sexual behavior. Physical exam revealed multiple well-defined, punched-out 0.3 cm × 0.3 cm indurated ulcers with rolled margins and yellowish slough-covered bases on the glans penis (Figure 1a). No regional lymphadenopathy was noted. Dermoscopic examination showed serpentine, coiled capillary loops, twisted vessels, and hairpin loop vessels against an orangish-yellow background (Figure 1c). Investigations indicated an elevated erythrocyte sedimentation rate of 50 mm. Gram stain, Tzanck smear, human immunodeficiency virus (HIV) serology, and rapid plasma reagin tests were negative. An autoimmune workup, including connective tissue disease panels, also returned negative results. Chest X-ray, abdominal ultrasound, and intravenous urography were unremarkable. Histopathological examination disclosed granulomatous inflammation with multiple Langhans-type giant cells (Figure 2a–d). The tuberculin skin test (TST) showed a vesicular reaction (Figure 1d), whereas the interferon-gamma release assay (IGRA) was positive. Polymerase chain reaction (PCR) and tissue culture for Mycobacterium tuberculosis and atypical mycobacteria were negative [3]. These findings confirmed the diagnosis of primary tuberculosis of the glans penis. The patient started a standard anti-tuberculosis regimen of isoniazid (400 mg), rifampicin (600 mg), pyrazinamide (1500 mg), and ethambutol (1200 mg) daily for 4 months (intensive phase), followed by isoniazid (400 mg) and rifampicin (600 mg) daily for 2 months (continuation phase). The lesions resolved post-treatment (Figure 1b). Genitourinary tuberculosis makes up about one-third of EPTB cases; however, isolated involvement of the glans penis remains exceptionally rare. A systematic literature search utilizing the keywords “primary tuberculosis of the glans penis” identified only 44 cases since 1912, highlighting diagnostic challenges. Primary genital tuberculosis generally involves direct inoculation, contact with infected fomites, or spread from the urinary tract. Secondary tuberculosis arises from hematogenous dissemination from a pulmonary or abdominal focus. Clinical presentations vary widely, ranging from papular lesions and ulcers to fungating masses that mimic penile carcinoma [4]. Confirmation typically requires mycobacterial culture, which can take up to 6 weeks. PCR offers faster results (24–48 h) but may yield false negatives in pauci-bacillary cases, as seen in our patient [3]. Histopathology reveals granulomatous inflammation with caseous necrosis, and positive results from both TST and IGRA further substantiate the diagnosis in suspected cases. Our patient had previously received multiple treatments for presumed sexually transmitted infections (doxycycline 100 mg × 15 days, azithromycin 1 g stat), Behçet disease (prednisolone 50 mg daily × 7 days), and hidradenitis suppurativa (doxycycline 100 mg twice daily × 3 months), with minimal symptom relief and no anti-TNF therapy administered. Prior corticosteroid use may have transiently modulated the inflammatory response, contributing to diagnostic delay. Differential diagnoses considered included syphilis, chancroid, herpes simplex virus, Behçet disease, hidradenitis suppurativa, fixed drug eruption, Crohn's disease, squamous cell carcinoma, and fungal infections. Delays in biopsy and TST highlighted the importance of early tissue sampling, whereas chronicity, histopathology, and positive TST/IGRA confirmed the diagnosis in this paucibacillary case. Timely diagnosis and treatment are crucial; untreated disease may lead to meatal stenosis and erectile dysfunction, significantly affecting quality of life [5]. Screening sexual partners is vital; the patient's partner tested negative for tuberculosis. This case highlights the need for a high suspicion index for tuberculosis in patients with chronic, non-healing genital ulcers, particularly in endemic areas. Early biopsy and appropriate microbiological and histopathological examinations are critical for prompt diagnosis and treatment, preventing potential long-term sequelae. The authors have nothing to report. The authors declare no conflicts of interest. The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.