Synchronous pancreatic and scrotal tuberculosis: Double jeopardyST Patel1, QQ Contractor1, CS Nayak2, PM Rathi1
1 Department of Gastroenterology, Topiwala National Medical College and BYL Nair Ch Hospital, Mumbai, Maharashtra, India
2 Department of Dermatology, Topiwala National Medical College and BYL Nair Ch Hospital, Mumbai, Maharashtra, India
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/jpgm.jpgm_558_22
Source of Support: None, Conflict of Interest: None
Keywords: Pancreatic tuberculosis, scrotal tuberculosis, tuberculosis
Scrotal tuberculosis (TB) is a rare form of extrapulmonary TB. Diagnosis is usually established with fine needle aspiration cytology or biopsy of the scrotal mass or examination of the discharging fluid for GeneXpert and/or culture for Mycobacterium TB (MTB). Occasionally, diagnosis is established only after surgical resection of the scrotal mass.
Pancreatic TB is also similarly a rare extra-pulmonary presentation of TB., The symptoms may be non-specific and imaging features are more likely to suggest pancreatic malignancy or chronic pancreatitis. Diagnosis is delayed due to the relative inaccessibility of the pancreas for tissue acquisition. With the advent of endosonographic-guided tissue acquisition, this problem has reduced to some extent, although a diagnosis is occasionally made only after a Whipple's resection for suspected carcinoma of the pancreas.
For two rare extrapulmonary presentations of TB to occur simultaneously in the same patient would be very rare indeed. Even in India which accounts for 25% of global TB patients, the simultaneous occurrence of scrotal and pancreatic TB has not been described nor has it been reported in the medical literature. We present a young patient in whom these two rare forms of extrapulmonary TB were present synchronously.
A 19-year-old male student presented with left-sided painful scrotal swelling following local trauma 4 weeks before presentation. Two weeks later, he developed two discharging sinuses over the scrotum. Local examination revealed scrotal swelling with overlying hyperemia and edema with two discharging sinuses [Figure 1]a.
Complete blood count revealed hemoglobin of 13 gm%, leucocyte count of 7800/microlitre, and platelet count of 280,000/microlitre. Liver function tests revealed total bilirubin of 1.0 mg%, aspartate aminotransferase of 30 IU/L, alanine aminotransferase of 28 IU/L, total protein of 7 gm%, albumin of 4 gm%, and international normalized ratio of 1.0 with a raised alkaline phosphatase of 432 IU/L. Gamma-glutamyl transferase was raised (156 U/L). Serum amylase was 36 IU/L and lipase was 43 IU/L. Human immunodeficiency virus (HIV) (ELISA) and Venereal disease research laboratory test (VDRL) were negative. X-ray chest was normal. Ultrasonographic examination of the scrotum showed chronic left epididymitis with chronic funiculitis.
The patient was treated with antibiotics for 2 weeks with no respite in his symptoms. At this time, TB was considered and a scrotal sinus aspirate was sent for GeneXpert and TB culture. GeneXpert detected MTB with Rifampicin sensitivity. TB culture was negative.
When he was in the hospital, he complained of upper abdominal pain and underwent ultrasonography of the abdomen. It showed an ill-defined heterogeneous, hypoechoic mass, in the head of the pancreas, engulfing the distal end of the common bile duct. Kidneys and urinary bladder were normal. CT scan of the abdomen showed an ill-defined heterogeneously enhancing lesion in the head of the pancreas measuring approximately 6.7 × 5.1 × 5.3 cm [Figure 1]b. Few arterial phase hyper-enhancing areas were seen within this lesion. The rest of the pancreatic parenchyma was normal. There was gradual and smooth tapering of distal Common bile duct (CBD) with proximal dilatation of the intra-hepatic bile ducts. Proximal CBD measured 2.1 cm. The pancreatic duct was also dilated to 4.4 mm giving a double duct sign [Figure 2]b. Laterally, the lesion showed loss of fat planes with the first and second parts of the duodenum. Medially, it showed a loss of fat planes with the portal vein and a 360-degree encasement of the gastroduodenal artery. There were multiple abdominal lymph nodes, the largest 1.8 × 1.1 cm in the right para-aortic region. A possibility of the inflammatory or infiltrative lesion and pancreatic adenocarcinoma was raised. Serum IgG4 levels and CA 19-9 were normal.
Endoscopic ultrasound (EUS) showed a mildly hypoechoic to an isoechoic lesion of size 6.5 × 5.2 cm with hyperechoic foci in the head of the pancreas [Figure 2]a. Mass was free from celiac vessels and was infiltrating the duodenum. Fine needle biopsy from the mass showed benign pancreatic parenchyma with mild chronic inflammatory infiltrate and fibrosis. GeneXpert for MTB was positive and culture was negative for TB.
Based on the GeneXpert positive report, he was started on anti-tubercular therapy consisting of Isoniazid, Rifampicin, Pyrazinamide, and Ethambutol for 2 months followed by Isoniazid, Rifampicin, and Ethambutol for 4 months. On follow-up examination at 2 months, the patient was asymptomatic with a resolution of the scrotal swelling and healing of the draining sinuses. After 6 months of anti-TB therapy, the scrotum was normal on examination [Figure 3]a. A repeat CT scan of the abdomen showed a reduction in the size of the pancreatic mass [Figure 3]b. The patient was advised to continue anti-TB drugs for another 3 months.
We describe a patient who presented with scrotal swelling followed by non-healing and discharging scrotal sinuses, following local trauma. An evaluation revealed it to be scrotal tuberculosis. While evaluating for abdominal pain, he was detected to have a mass in the head of the pancreas which turned out to be pancreatic tuberculosis. Both lesions responded well to anti-tubercular therapy. This is an unusual case of two rare sites of extrapulmonary tuberculosis presenting simultaneously in the same individual.
Scrotal TB which is usually secondary to genital TB with testicular and epididymal involvement is considerably rare even in countries endemic for TB., It is postulated that genital TB occurs secondary to spread from the kidneys to the urinary bladder and from there to the prostrate, followed by canalicular spread to the seminal vesicle, deferent duct, and epididymis., Viswaroop et al. found in their study that 54 of 187 men with isolated genital tuberculosis had tuberculous epididymitis. Fourteen were subsequently excluded from their analysis. They found scrotal sinus in 4 (10%). Testicular involvement occurred in 3% of genital TB and was due to local spread or retrograde seeding from the epididymis and rarely by hematogenous spread.,, Transurethral reflux of MTB caused by factors such as trauma, alcohol abuse, and excessive sexual activity has been postulated. Scrotal tuberculosis is a rare presentation of extrapulmonary TB.
Similarly, pancreatic TB is thought to be rare., It can be easily mistaken for pancreatic neoplasm due to its presentation as a pancreatic mass and the presence of double duct sign or vessel involvement, as was seen in our patient. Features against adenocarcinoma of the pancreas included young age with no history of jaundice or weight loss and normal CA 19-9 levels. We considered autoimmune pancreatitis, however, his serum IgG4 level was normal. Chronic pancreatitis was another possibility but the lack of severe abdominal pain, maldigestion, or diabetes made this unlikely. Lymphoma was considered in view of mass lesion and the presence of multiple enlarged lymph nodes. Tuberculosis was considered as it can have a similar presentation. In view of these different possibilities, an EUS-guided tissue acquisition was done. Although histopathology was non-specific, a positive GeneXpert and dramatic response to anti-tubercular treatment confirmed the diagnosis of tuberculosis.
This is a rare case of synchronous presentation of two rare forms of extrapulmonary tuberculosis. Tuberculosis can indeed be a great masquerader.
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[Figure 1], [Figure 2], [Figure 3]