Tuberculous epididymo-orchitis and papulonecrotic tuberculids of the glans penis

SC Murthy, MM Udagani, BM Kajagar

 Departments of Dermatology and Venereology and Surgery, S. N. Medical College and HSK Hospital and Research Centre, Bagalkot - 587101, India

Correspondence Address:
S C Murthy
Departments of Dermatology and Venereology and Surgery, S. N. Medical College and HSK Hospital and Research Centre, Bagalkot - 587101
India

Introduction

Tuberculosis is still a major cause of morbidity in developing countries like India. Cutaneous tuberculosis is also not uncommon in our country. Tuberculids represent a cutaneous hypersensitive response to an underlying focus of tuberculosis. Papulonecrotic tuberculids over the glans penis is a rare occurrence. We report papulonecrotic tuberculids of the glans penis manifesting secondary to bilateral tuberculous epdidymo-orchitis.

Case Report

A 25-year-old male presented with recurrent crops of multiple asymptomatic papulo-pustules over the glans penis of 3 months′ duration. These used to resolve spontaneously in a few days with scarring. He had an asymptomatic, right sided scrotal swelling of the same duration. He was treated with injection benzathine pencillin, systemic antibiotics and various topical applications before referral. There was no history of trauma, drug intake, fever, cough and constitutional symptoms. There was no personal or family history of tuberculosis. The patient denied exposure to sexually transmitted diseases. He had not been vaccinated with BCG.

Examination revealed a few erythematous, nontender, papules, pustules, and confluent pitted scars over the glans penis [Figure - 1]. There was right sided hydrocele with a firm, indurated, mildly tender epididymis and a thickened vas with orchitis. There was thickening of the epididymis and vas with a beaded appearance on the left side. There was no significant inguinal lymphadenopathy. Muco-cutaneous, appendageal and systemic examinations were normal.

The following are results of relevant investigations: neutrophilia (73%) absolute eosinophil count 150, ESR (Westergren′s method) 70 mm/hr, blood VDRL non-reactive, HIV-1 and-2 (ELISA) negative, and mantoux test strongly positive (25 x 20 mm induration). The chest X-ray showed evidence of healed tuberculosis. X-ray and ultrasound KUB were normal. Ultrasound examination of the scrotum showed evidence of hydrocele, and patchy calcifications of the epididymis, vas, and seminal vesicles on both sides. Urine culture for bacteria/AFB growth was negative. Pus from a pustule showed no organisms on grams and Ziehl-Neelsen staining and culture. The patient refused semen analysis. Fine needle aspiration from a nodule of the vas showed features consistent with tuberculosis. Histopathology from a papule over the glans was consistent with papulonecrotic tuberculids.

He was put on antitubercul no treatment (ATT) for six months. Two weeks after the initiation of therapy, the existing lesions over the glans had healed. Further follow-up showed improvement in the condition and no recurrence.

Discussion

The concept of tuberculids was introduced by Darier in 1896. Tuberculids are symmetric eruptions in response to an internal focus of tuberculosis in an individual with a moderate or high degree of immunity. Papulonecrotic tuberculids are asymptomatic, symmetrical, dusky red papules which heal with scarring. The sites of predilection are the elbows, knees, legs, hands, feet, but the ears, face, buttocks and penis can be affected.[1] Involvement of the glans penis was first described by Hellerstrom and later by Bafverstedt and Hageman and Granroth.[2] The occurrence is commoner in Japan and has been termed as penis tuberculides.[3] A few reports have been documented from other parts of the world from India.[2],[4],[5],[6],[7],[8]

The basic diagnostic criteria for papulonecrotic tuberculids are: a strongly positive mantoux test, typical clinical features, a tuberculoid histology with endarteritis and thrombosis of the dermal vessels, and response to ATT.[2] The histological findings may be sometimes inconclusive, showing a non-specific or tuberculoid picture.[4] The spectrum of histological findings ranges from acute leukocytoclastic vasculitis in early lesions to mature granuloma formation in older ones. The proof of diagnosis rests on the unequivocal response to ATT.[5]

An analysis of 91 cases of papulonecrotic tuberculids showed a deep focus in about one-third of the cases (38%). Involvement of lymph glands was the commonest and a urogenital focus the least common.[9] Them majority of cases of papulonecrotic tuberculids of glans penis reported[2],[3],[4],[6],[8] earlier lacked an underlying tuberculous focus, but our case had an active focus.

Our case was unique in that there was an association of healed pulmonary focus, bilateral active tuberculous epidydmo-orchitis with involvement of the seminal vesicles and papulonecrotic tuberculids of the glans penis, which to the best of our knowledge has not been reported earlier. Kashima et al reviewed 26 cases of penile tuberculids reported for the last 13 years, who found co-existing tuberculosis elsewhere in four cases only.[10]

Although tuberculosis is common, tuberculids of the penis are rarely reported even in endemic countries like India. Diagnosis is possible by awareness of the condition, strong suspicion and relevant investigations. An underlying active or healed focus of tuberculosis should be thoroughly searched for.

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