Role of fine needle aspiration cytology in primary tubercular epididymo-orchitis

Arghya Bandyopadhyay; Subhadip Khatua; Kousik Bose; Nikhilesh Dewasi

doi:10.4103/0975-9727.146471

CASE REPORT

Year : 2015 | Volume : 6 | Issue : 1 | Page : 75-77

Role of fine needle aspiration cytology in primary tubercular epididymo-orchitis

Arghya Bandyopadhyay, Subhadip Khatua, Kousik Bose, Nikhilesh Dewasi
Department of Pathology, Burdwan Medical College, Burdwan, West Bengal, India

Date of Web Publication

8-Dec-2014

Correspondence Address:
Arghya Bandyopadhyay
Department of Pathology, Burdwan Medical College, PO - Burdwan, Burdwan - 713 104, West Bengal
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/0975-9727.146471

Abstract

Tubercular epididymo-orchitis in not uncommon in a highly tuberculosis-prevalent developing country like India. However, it closely mimics a testicular tumor clinically, radiologically, and even serologically. This may lead to an unnecessary orchidectomy. Nevertheless, fine needle aspiration cytology can provide adequate material for cytological and microbiological examination and it helps to avoid unnecessary orchidectomy when there is suspicion of a testicular tumor.

Keywords: Cytology, orchitis, tubercular, tumor

How to cite this article:
Bandyopadhyay A, Khatua S, Bose K, Dewasi N. Role of fine needle aspiration cytology in primary tubercular epididymo-orchitis. Muller J Med Sci Res 2015;6:75-7

How to cite this URL:
Bandyopadhyay A, Khatua S, Bose K, Dewasi N. Role of fine needle aspiration cytology in primary tubercular epididymo-orchitis. Muller J Med Sci Res [serial online] 2015 [cited 2023 Jun 6];6:75-7. Available from: https://www.mjmsr.net/text.asp?2015/6/1/75/146471

Introduction

Tubercular epididymo-orchitis is not uncommon in a developing country like India. ^[1] Overall, tuberculosis of the scrotal contents occurs in approximately 7% of the patients with tuberculosis. Prevalence of an associated history of previous tuberculosis infection ranges from 0 to 70% in all cases. ^[2] However, clinically, radiologically, and even serologically this can mimic a testicular tumor, which leads to unnecessary orchidectomy. Herein, we present two cases of primary tubercular epididymo-orchitis that had presented as testicular mass lesions. The first one was diagnosed as tuberculosis only after histopathological examination, but the second one was diagnosed with the help of a Fine Needle Aspiration Cytology (FNAC) smear, where the patient was treated successfully with anti-tubercular drug (ATD), avoiding unnecessary orchidectomy.

Case Report

Our first case was a 32-year-old male patient, who presented with a hard left scrotal mass, with thickening of overlying scrotal skin. There was no past history of tuberculosis or exposure to tuberculosis. He was non-reactive for human immunodeficiency virus (HIV). The patient had no fever. There had mild lymphocytosis, but the other hematological parameters were unremarkable. His renal and liver function tests, serum beta-human chorionic gonadotropin (HCG), and alpha fetoprotein (AFP) were normal, but his lactic acid dehydrogenase (LDH) (623 U/L, normal 115-221 U/L) and Alkaline Phosphatase (ALP) (288 U/L, normal 33-96 U/L) were high. A chest x-ray and ultrasonography (USG) of the entire abdomen was unremarkable. The USG of the testis showed an enlarged left testis, along with left epididymis having a heterogeneous echotexture. There was a suspicion of a testicular tumor. Thus, left-sided orchidectomy was performed, which on grossing showed thickening of the overlying scrotal skin and multiple coalescing, small, whitish nodules replacing the normal testis [Figure 1]. Sections were taken from different areas for histopathological examination. The Hematoxylin and Eosin (H&E)-stained sections showed multiple caseating epithelioid granulomas with Langhans-type giant cells replacing a major part of the normal seminiferous tubules. The Ziehl Neelsen (ZN) stain for Acid Fast Bacilli (AFB) was positive [Figure 2]. The patient was treated for extrapulmonary tuberculosis postoperatively.

Figure 1: Cut section of the left testis showing a thickened capsule, areas of caseation necrosis, and fibrosis

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Figure 2: (a) The histopathological section from the left testis showing normal testicular elements is replaced by epithelioid cell granuloma; (b) A higher power view showing typical caseating granuloma and presence of Langhans-type giant cells (10× and 40×, Hematoxylin and Eosin stain); (c) ZN stained section showing acid fast bacilli of Mycobacterium tuberculosis (100×)

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The second case was of a 31-year-old, unmarried male, who presented with gradually increasing right scrotal swelling for the last two months, with weight loss, dysuria, frequent episodes of low-grade fever, and lymphocytosis in the blood picture. The clinicians suspected that it was a case of epididymo-orchitis, although testicular tumor was the differential diagnosis. The USG of both testes showed a heterogeneous space-occupying lesion (SOL) in the right testis and epididymis. FNAC from the epididymis was performed. Stained smears showed the presence of epithelioid cell granuloma with multiple giant cells [Figure 3]. There was minimal caseous necrosis and a ZN-stain was non-contributory. Tubercular epididymo-orchitis was given as the provisional diagnosis and the patient was treated with ATD, with good response. Thus, by a simple FNAC, the physical and psychological trauma of orchidectomy was avoided in the case of the 31-year-old male patient.

Figure 3: The cytology smear from an epididymal nodule showing epithelioid granuloma, Langhans giant cells (arrow), and normal epididymal epithelial cells on a sheet (10×, Pap stain)

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Discussion

Testicular tuberculosis may coexist with pulmonary tuberculosis or tuberculosis of other parts of lower genitourinary system, including the bladder, ureter, and prostate. ^[3] Testicular involvement is mostly due to the local spread from the epididymis, retrograde seeding from the epididymis, and rarely by the hematogenous spread. A hematogenous spread is more common in the epididymis or prostate, due to their rich blood supply. Clinically, patients present with a painless or slightly painful scrotal mass. The presence of epididymal enlargement, together with a testicular lesion is suggestive of infection rather than a tumor, because orchitis is usually caused not only by epididymitis, but a tumor also, which may partially involve the epididymis in the advanced stage of the disease. ^[4] However, isolated tubercular orchitis does occur rarely. Elevated serum lactate dehydrogenase (LDH) and human chorionic gonadotropin (HCG) can be seen in both tubercular orchitis and testicular tumor. ^[2] Thus, this diagnostic dilemma may result in an inappropriate surgical procedure for a potentially curable medical illness. A high index of suspicion, scrotal ultrasound, and FNAC can be quite helpful in the diagnosis. In tubercular orchitis FNAC smears usually reveal epithelioid granuloma with or without Langhans giant cells and a caseous necrotic material, sometimes with polymorphs. AFB may or may not be demonstrated in ZN staining. ^[5]

Historically, surgeons have been hesitant to aspirate a scrotal mass lesion in fear of the possibility of seeding an early stage testicular tumor. The magnitude of such a procedure is unknown and not substantiated by convincing evidence. FNAC does not have the same potential for seeding or local spread that a needle core biopsy has. ^[6] Furthermore, there is no evidence to suggest that FNAC of testicular tumors predisposes to local recurrence or inguinal lymph node metastasis. ^[7] FNAC with immediate surgery, including the excision of a needle tract, can follow, if malignancy is detected. ^[8] According to Perez-Guillermo et al., FNAC is the technique of choice for the scrotal content and it must be employed on the patient's very first visit, for early diagnosis. ^[9] For a granulomatous lesion FNAC helps to avoid unnecessary orchidectomy, as in our second case, where tubercular epididymo-orchitis was diagnosed by FNAC and treated well with an ATD, avoiding orchidectomy.

Conclusion

Fine needle aspiration cytology of a scrotal swelling is a minimally invasive technique, and plays a great role in proper early diagnosis and helps to differentiate tubercular epididymo-orchitis from a testicular tumor. Therefore, FNAC must be offered before going for unnecessary orchidectomy.

Acknowledgment

The authors are thankful to Dr. K Konar and Prof. U Banerjee for their help and support.

References

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