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GLOBAL JOURNAL OF MEDICINE AND PUBLIC HEALTH
1 www.gjmedph.org Vol. 3, No. 4 2014 ISSN#-‐ 2277-‐9604
Prostatic abscess by ‘the great imitator’ in a HIV patient -‐ a case report. Pandurangan Thilakavathy1*, R.M.Sathish Kumar 2 , Anand B. Janagond 3 , G.S.Vijay Kumar 4
ABSTRACT Tuberculosis (TB) of prostate is a very rare condition. We present a case of primary prostatic tubercular abscess in a young HIV seropositive patient. There was no classical clinical presentation of tuberculosis in the patient. Microbiological analysis of aspirated pus from prostatic abscess showed plenty of inflammatory cells in Gram stained direct smear and Ziehl Neelsen staining showed acid fast bacilli. Retrospective detailed interrogation of the patient and further investigations aided in the diagnosis of prostatic tubercular abscess. Keywords: Tuberculosis, prostatic abscess, acid fast bacilli INTRODUCTION Genitourinary tuberculosis (GUTB) is the second commonest extra pulmonary tuberculosis. Thorough knowledge, epidemiology of tuberculosis (TB) in the region and a strong clinical suspicion is very essential for early diagnosis. India and China together have more than 50% of global TB cases; many of these are multidrug resistant (MDR) cases. About 4% of new and 20% of old TB cases are found to be MDR-‐TBs. TB is also known as ‘the great imitator’ because of its varied clinical presentation. GUTB may not present with classical presentation, majority of cases may have only sterile acidic pyuria. Only 20% cases have detectable primary focus. HIV infected persons are more vulnerable to GUTB and the rate varies from 15 – 50%. Mycobacterium tuberculosis (MTB) is older to humans and it has diverse adaptability. Despite the effort of World health organization (WHO) and the entire world, TB control has not been successful. With the emergence of unholy nexus between TB and HIV, newer problems have cropped in the presentation, diagnosis and management of TB. In recent times there has been a spurt in the occurrence of extrapulmonary TB. 10 – 14 % of extrapulmonary TB cases involve genitourinary system. [1] Primary
prostatic tubercular abscess without any predisposing factors occurring in young patients is increasing. Non specific presentation and absence of a classical sign has made clinical diagnosis of prostatic abscess impossible. Modern radiological diagnostic methods like transrectal ultrasound (TRUS) and computed tomography (CT) have facilitated the diagnosis of prostatic abscess. [2] The double edged sword of HIV-‐ TB has complicated therapeutics of tuberculosis including prostatic abscess due to emergence of Multi drug resistance in MTB and HIV strains. CASE REPORT A 37 years old male patient presented with history of intermittent urinary retention for six months and burning micturition since a fortnight was evaluated by the urologist. General physical examination was found normal. Routine haematological and biochemical investigation parameters were within normal limits, except marginally elevated ESR (25 mm). X-‐ray chest was normal. Digital per rectal examination showed nodular prostate and boggy right lobe. Ultrasonography (USG) of the abdomen
GJMEDPH 2014; Vol. 3, issue 4 *Corresponding author: thilaka_doctor@yahoo.co.in 1 Assistant Professor VMCH & RI, Department of Microbiology, Madurai, India 1 Assistant Professor VMCH & RI, Department of Urology, Madurai, India 3 Associate Professor VMCH & RI, Department of Microbiology, Madurai, India 4 Professor & Head Assistant Professor VMCH & RI, Department of Microbiology, Madurai, India Conflict of Interest—none Funding—none
2 www.gjmedph.org Vol. 3, No. 4 2014 ISSN#-‐ 2277-‐9604
Case report
revealed a hypoechoic lesion in the posterior lobe of prostate suggestive of prostatitis with abscess. CT scan abdomen showed hyperdense, enlarged lymph nodes having central necrosis in the periportal, peripancreatic, paraaortic, aortocaval and retrocaval regions. Prostate was enlarged and there were irregular hypodense areas involving right and left lobes. There was indenting of the anterior wall of rectum. CT scan findings also favoured prostatitis with abscess (fig -‐1). TRUS guided aspiration was done and about 5 ml of thick blood mixed pus was drained, prostate appeared heterogenous with increased vascularity. This aspirated fluid was sent to microbiology laboratory for bacteriological examination. Microscopic examination of Gram stained smear showed plenty of polymorphs; but no bacteria were found. A Ziehl Neelsen (ZN) stained smear examination showed plenty of acid fast bacilli. Aerobic culture of the fluid was sterile at the end of 48 hrs.
TRUS guided prostatic tissue biopsy was done, histopathological diagnosis of the tissue was granulomatous prostatitis possibly tuberculosis (fig-‐2). CT scan screening of whole body was done to find out the primary focus. There was no evidence of primary tuberculosis elsewhere in the body. By this we confirmed the primary prostatic tubercular abscess of the case. Patient’s age, occupation and AFB positivity led to suspicion of possible co-‐existing HIV infection. As per NACO guidelines, he was counselled and with his written consent, blood was drawn and tested for HIV seropositivity. He was found reactive for HIV-‐1. During post test counselling the patient was told about TB –HIV and the schedule of treatment. Patient has been referred to HAART & RNTCP centre for further treatment.
Figure 2 HPE : showing prostatic tissue with focal collections of epitheloid cells forming granulomas
surrounded by lymphocytes and fibroblasts
Figure 1 CT Image showing abscess DISCUSSION Prostatic tubercular abscess is an unusual, but curable infectious disease. In an Indian study analysing 48 prostatic abscesses only one was a case of tubercular aetiology. [3] Majority of tubercular prostatitis cases are asymptomatic. Prolonged duration of local symptoms and a normal WBC count confuses the diagnosis of tubercular abscess. Clinical presentation of prostatic abscess has undergone a sea change in this antibiotic era. Tubercular prostatic
abscess diagnosis needs a high degree of suspicion, proper processing of the material and thorough scanning of the smear for microscopic detection of AFB. TB Prostate is always secondary to pulmonary or renal TB. Spread from primary foci is by haematogenous route. Primary focus may not be detected in many of the extra pulmonary tuberculosis cases. It could be due to reactivation of a primary focus in persons with remote history of TB. [4] Seeding of prostate may also occur from a microscopic focus elsewhere in the body, which may not be detected. Prostatic tubercular abscess is
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Case report
known to occur as a post treatment complication in patients with non invasive bladder cancer cases who were treated with intravesicle BCG. [5] Majority of prostatic tuberculosis cases may be quiescent, without any obvious signs and symptoms. Retention of urine may be the only presenting complaint in some cases. Our patient also had intermittent urinary retention, but he did not have any other TB related clinical features. Exact mechanism of pathogenesis of tubercular prostatic abscess in HIV patients is not clearly known. TB Prostate is more often diagnosed by urologists during transurethral resection. Many patients have lower urinary tract obstruction, suggesting urinary stasis in the pathogenesis of prostatic abscess. Delay in diagnosis and initiation of proper treatment may result in spread to adjacent tissue or organs forming sinuses or fistulae to the perineum or rectum, perivesical space, as well as into the peritoneum and
bladder. Antitubercular therapy and ultrasound guided drainage of the abscess will completely cure prostatic tubercular abscess. Our patient has been referred to HAART & RNTCP centre for further treatment. CONCLUSION It is important to suspect tubercular abscess in a patient with history of urinary voiding problems and thorough examination is vital to rule out TB. Aspiration of the fluid and submitting for detailed laboratory examination should not be neglected. ACKNOWLEDGEMENTS M.Mariappan, assistant professor at the department of radiodiagnosis, VMCH&RI. K.Yegumuthu assistant professor at the department of pathology, VMCH&RI.
REFERENCES
1. Wise Gilbert J, Venkata K. Genitourinary manifestations of tuberculosis. Urologic Clinics of North America. 03/2003; 30(1):111–21.
2. Cytron S, Weinberger M, Pitlik SD, Servadio C: Value of transrectal ultrasonography for diagnosis and treatment of prostatic abscess. Urology. 1988; 32: 454-‐8.
3. Jigish B Vyas, Sanika A Ganpule, Arvind P Ganpule, Ravindra B Sabnis, and Mahesh R Desai Transrectal ultrasound-‐guided
aspiration in the management of prostatic abscess: A single-‐center experience Indian J Radiol Imaging. 2013 Jul-‐Sep; 23(3): 253–257.
4. Ludwig M, Velcovsky HG, Weidner W. Tuberculous epididymo-‐orchitis and prostatitis: a case report. Andrologia. 2008;40: 81–83.
5. Seung Whan Doo, Jae Heon Kim, and Yun Seob Song; A Case of Tuberculous Prostatitis with Abscess. World J. Mens health. Aug 2012; 30 (2): (138 – 140).
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