Tuberculous Orchiepidimitis In InsulinDependent Type 2 Diabetes Mellitus: A Case Report
Gonzalo Carrillo-Sanabria 1,2,a*, Brian Davila-Aranda 1,2,a,, Rodolfo CairoHuaringa 3,b, Richard Maita-Hinostroza 3,c, Jorge Chumbes-Perez 3,d
1Faculty of Human Medicine, Peruvian University Los Andes. Huancayo, Peru
2Scientific Society of Medical Students Los Andes (SOCIEMLA). Huancayo-Peru.
3National Hospital “Ramiro Prialé Prialé” R.A.J. Huancayo-Peru
aStudent of the 6th year of the Human Medicine degree.
bMedical specialist in Radiology.
cMedical specialist in Pathological Anatomy.
dMedical specialist in Infectology.
*Gonzalo Carrillo Sanabria, Faculty of Human Medicine, Peruvian University Los Andes. Huancayo, Peru
Figure 1 : Histology of the right testicle showing seminiferous ducts with chronic inflammatory infiltrate and formation of incomplete granulomas with the presence of Langhans-type giant cells.
Figure 2: Computed tomography of the chest in the pulmonary window where no tomographic signs of parenchymal lesion suggestive of tuberculosis are observed.
Physical examination findings may include a tender nodule, dilation, and thickening of the epididymis. Testicular involvement can be unilateral or bilateral. Epididymal involvement classically shows up as a heterogeneous hypoechoic mass on ultrasonography. In the urinalysis, albuminuria or hematuria may also be observed. Others report cases of infertility (7).
Clinically, it is usually indistinguishable from testicular tumor, acute infection (bacterial or viral), granulomatous infection (sarcoidosis) or infarction, and can even, in some cases, mimic testicular torsion (5). Epididymal enlargement and thickening of the scrotum are the key points of infection.
Testicular ultrasound is currently the best technique for the diagnosis of testicular injury. Here, a great thickening and formation of a dense, caseous mass is observed, which can rupture and give rise to tedious fistulas. Other sonographic findings include thickening of the scrotal skin, hydrocele, calcifications, and scrotal abscess. The addition of Doppler ultrasound serves to assess blood flow and helps differentiate testicular infarction, tumor, or inflammation (5).
Regarding the presence of DM, data indicate that having HA1C greater than seven is a risk factor for latent tuberculosis (9). In addition, there are differences in the pharmacokinetics of drugs for TB and DM and other comorbidities such as hypertension or obesity, which leads to a higher risk of death and relapse (10).
In our case, a patient with immunosuppression, diabetes, compatible symptoms, and histology with epithelioid granulomas, caseous necrosis, and Ziehl-Neelsen staining confirmed the diagnosis.
The evidence recommends antituberculous treatment with the usual regimen of isoniazid, rifampicin, pyrazinamide, and ethambutol (2HRZE + 4HR) for 6 months, through which cure rates of 95% are obtained. However, surgical intervention may be necessary; especially in severe cases, such as no clinical response to treatment, increased testicular size, and edema or abscess formation (11).
One of the challenges that occurs in patients with DM-TB is therapeutic management, since it has been shown that the levels of anti-TB drugs in plasma are below therapeutic values (12). This, added to hyperglycemia, makes management difficult.
There are still no randomized studies that evaluate an adequate treatment for TB-DM, and there is not enough evidence to evaluate the effect of insulin or metformin (13), with the use of insulin being recommended in Peru (14).
In endemic countries such as Peru, patients with symptoms such as long-standing dysuria and frequency, scrotal mass, or chronic epididymitis should be evaluated for tuberculosis. This would significantly reduce any delay in establishing a diagnosis which would increase the chances of quick management and recovery. A surgical approach should be considered only in cases where the diagnosis is not clearly established or when there is a strong clinical indication.
This report was self-financed by the authors.
CONFLICT OF INTERESTS:
All authors declare no conflicts of interest.
- WHO. Global tuberculosis report 2016. World Health Organization, Geneva; 2016. http://www.who.int/tb/publications/global_report/en/. Accessed May 12,2017.
- Dooley KE, Chaisson RE. Tuberculosis and diabetes mellitus: convergence of two epidemics. Lancet Infect Dis. 2009;9(12):737-46.
- Miranda JJ, Herrera VM, Chirinos JA, Gómez LF, Perel P, Pichardo R, et al. Major cardiovascular risk factors in Latin America: a comparison with the United States. The Latin American Consortium of Studies in Obesity (LASO). PLoS One.2013;8(1):e54056.
- Magee MJ, Bloss E, Shin SS, Contreras C, Huaman HA, Ticona JC, et al. Clinical characteristics, drug resistance, and treatment outcomes among tuberculosis patients with diabetes in Peru. Int J Infect Dis. 2013;17(6):e404-12.
- Muttarak, M and Peh, WC. Case 91: tuberculous epididymo-orchitis. Radiology. 2006; 238: 748–751.
- Kapoor R, Ansari MS, Mandhami A, Gulia A. Clinical presentation and diagnostic approach in cases of genitor urinary tuberculosis. Indian J. Urol. 2008; 24(3):401–405.
- Figueiredo AA, Lucon AM, Srougi M. Urogenital tuberculosis. Microbiol Spectrum 2017; 5 (1) 1-16.
- Kumar V, Abbas A, Aster J. Robbins, and Cotran. Structural and functional pathology. Barcelona, Spain: Elsevier; 2015. p. 371-376
- Martínez G, Serrano C, Castañeda J, Macías N, Hernández N, Enciso L, et al. Associated Risk Factors for Latent Tuberculosis Infection in Subjects with Diabetes. Arch Med Res 2015; 46(3): 221-7
- Miranda JJ, Bernabe-Ortiz A, Stanojevic S, Malaga G, Gilman RH, Smeeth L. A1C as a diagnostic criteria for diabetes in low- and middleincome settings: evidence from Peru. PLoS One. 2011;6(3):e18069.
- Baker MA, Harries AD, Jeon CY, Hart JE, Kapur A, Lönnroth K, et al. The impact of diabetes on tuberculosis treatment outcomes: a systematic review. BMC Medicine. 2011;9(1):81.
- Babalik A, Ulus IH, Bakirci N, Kuyucu T, Arpag H, Dagyildizi L, et al. Plasma concentrations of isoniazid and rifampin are decreased in adult pulmonary tuberculosis patients with diabetes mellitus. Antimicrob Agents Chemother. 2013;57(11):5740-2.
- Ruslami R, Aarnoutse RE, Alisjahbana B, van der Ven AJ, van Crevel R. Implications of the global increase of diabetes for tuberculosis control and patient care. Trop Med Int Health. 2010;15(11):1289-99.
- Peru, Ministry of Health (MINSA). Technical Health Standard for the comprehensive care of people affected by Tuberculosis. Ministerial Resolution No. 715-2013/MINSA of November 8, 2013. Lima: MINSA; 2013.