|Year : 2020 | Volume
| Issue : 2 | Page : 296-298
Isolated left adrenal gland involvement in testicular tuberculosis
Pandiaraja Jayabal1, Shalini Arumugam2
1 Department of General Surgery, Dr. Mehta Hospital, Global Campus, Chennai, Tamil Nadu, India
2 Department of Community Medicine, ACS Medical College, Chennai, Tamil Nadu, India
|Date of Submission||18-Oct-2020|
|Date of Decision||12-Nov-2020|
|Date of Acceptance||17-Nov-2020|
|Date of Web Publication||23-Dec-2020|
Dr. Pandiaraja Jayabal
26/1, Kaveri Street, Rajaji Nagar, Villivakkam, Chennai - 600 049, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Testicular tuberculosis (TB) is commonly associated with genitourinary TB or as a part of miliary TB. In miliary type of testicular TB, there is often bilateral involvement of the adrenal gland. Our case presented with enlargement of the left adrenal gland only. This may be due to anomalous communication between the left gonadal vein and the left adrenal vein. He was started with antituberculous treatment with rifampicin, isoniazid, pyrazinamide, and ethambutol. The patient failed to respond to anti-TB treatment; therefore, he underwent left low inguinal orchidectomy, and the histopathology confirmed the diagnosis. The adrenal lesion started disappearing following orchidectomy and antituberculous treatment.
Keywords: Isolated involvement, left adrenal gland, miliary tuberculosis, testicular tuberculosis
|How to cite this article:|
Jayabal P, Arumugam S. Isolated left adrenal gland involvement in testicular tuberculosis. Arch Med Health Sci 2020;8:296-8
| Introduction|| |
Tuberculosis (TB) can affect any organ, starting from head to toe. Testicular TB is rare, and it is mostly due to secondary infection from the epididymis. TB testis most often is associated with genitourinary TB or as a part of miliary TB. Most of the testicular TB occurring as a part of miliary TB is present with bilateral enlargement of the adrenal gland. Our case presented with enlargement of the left adrenal gland.
| Case Report|| |
A 28-year-old male patient presented with a complaint of swelling in the left side of the scrotum for 2-week duration. He also complained of pain in the scrotal swelling associated with fever of 1-week duration. There was no history cough or expectoration. There was no history of loss of weight and loss of appetite. There was no history of previous surgery and prolonged medication. He denied a history of contact with TB. On examination, the patient was well built and nourished. There was no pallor, icterus, cyanosis, clubbing, pedal edema, or lymphadenopathy. His blood pressure was 100/70 mmHg and pulse rate – 110/min and respiratory rate – 18/min. Examination of the scrotum showed erythematous swelling on the left hemiscrotum [Figure 1]. There was no local warmth. There was tenderness on the left hemiscrotum. Multiple enlarged left inguinal lymph nodes were present. Abdominal examination, respiratory examination, cardiovascular examination, and spinal cord examination were within normal limits.
|Figure 1: A local examination of the scrotum shows erythematous scrotal swelling on the left hemiscrotum|
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The blood investigations showed an elevated erythrocyte sedimentation rate of 120 mm/in the 1st h. Renal function test and liver function test were within normal limits. Serology for HIV, hepatitis B surface antigen, and hepatitis C virus was negative. Mantoux test showed induration of 12 mm. The chest X-ray was unremarkable. Ultrasound scrotum showed multiple hypoechoic lesions present in the left testis along with thickened left hemiscrotal skin. Tuberculous testis was considered as one of the possible diagnoses based on the ultrasound findings. Further investigations were done to confirm whether it is primary testicular TB or as a part of miliary TB. Computed tomography (CT) of the chest was normal. CT of the abdomen showed a 1.8 cm × 1.5 cm hypodense lesion in the left adrenal gland [Figure 2]. Adrenal TB was considered based on the CT findings.
|Figure 2: Computed tomography of the abdomen shows a 1.8 cm × 1.5 cm hypodense lesion on the left the adrenal gland|
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He was started with antituberculous treatment with rifampicin, isoniazid, pyrazinamide, and ethambutol. The patient failed to respond to antituberculous treatment, therefore, planned for left low inguinal orchidectomy, and histopathology confirmed the diagnosis. The postoperative cut open specimen showed a multiple abscess collection of the entire testes [Figure 3]. Postoperative histopathology showed multinucleated giant cells and granuloma [Figure 4]. Adrenal lesions started disappearing following antituberculous treatment. The patient has been followed up for more than 5 years. He showed no evidence of residual adrenal TB or recurrence of the disease.
|Figure 3: Postoperative cut open specimen shows a multiple abscess collection of the entire testes|
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|Figure 4: Postoperative histopathology shows multinucleated giant cells and granuloma|
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| Discussion|| |
Primary TB mostly occurs through droplet infection in the lung. Postprimary TB mostly is reactivation of latent infection or reinfection with new bacilli. Testicular TB is around 1% of genitourinary TB. TB testis usually starts at the tail of the epididymis and spreads to the entire epididymis; later, it involves the entire testis. Genitourinary TB is more common in the epididymis, followed by the seminal vesicle, prostate, testis, and the vas deferens. TB testis is most often associated with genitourinary TB or as a part of miliary TB. Most of the testicular TB as a part of miliary TB is present with bilateral enlargement of the adrenal gland. Our case presented with left-side enlargement of the adrenal gland. Tuberculous testis sometimes mimics testicular tumor, torsion testis, and pyogenic epididymo-orchitis.
TB of the testis has numerous possible mechanisms of spread. TB orchitis develops from retrograde spread from the urinary tract into the prostate, seminal vesicle, vas deferens, and the epididymis. TB testis may also occur by the hematogenous and lymphatic spread. Testis receives arterial blood supply directly from the testicular artery and indirectly by the cremasteric artery and the deferential artery via the internal iliac artery. Venous drainage of the testis on the right side is through the testicular vein draining into the inferior vena cava, whereas on the left side, it directly drains into the left renal vein. The adrenal gland receives arterial supply from the superior and middle suprarenal arteries through direct branches of the aorta and inferior suprarenal artery through the renal artery. The right adrenal gland drains via the right suprarenal vein into the inferior vena cava, whereas the left adrenal vein drains into the left renal vein. There are reports of anomalous communication between the left gonadal vein and the left adrenal vein. This may be the reason for isolated the adrenal gland involvement in our case.
Most of the TB testis is diagnosed with ultrasound and image-guided fine-needle aspiration cytology. Sometimes, the diagnosis is difficult; therefore, we need to do orchidectomy for the diagnosis and treatment. Ultrasound examination of testicular tuberculosis may show hypoechoic micronodules, multiple nodules in the testis, hypervascularization of testis, enlarged epididymis, reactive hydrocele, testicular abscess with sinus tract formation and multiple intrascrotal calcification. TB testis divided into four types based on the ultrasound findings: (1) diffuse enlarged heterogeneously hypoechoic, (2) diffuse enlarged homogeneously hypoechoic, (3) nodular enlargement, heterogeneously hypoechoic, and (4) miliary type.
The treatment of tuberculous testis includes medical and surgical management. Most of the tuberculous testis can be managed medically using an antituberculous treatment. Rifampicin, isoniazid, pyrazinamide, and ethambutol are used as antituberculous drugs to treat testicular TB. Rifampicin, isoniazid, pyrazinamide and ethambutol is given for 2months followed by rifampicin and isoniazid for 4 months as standard treatment for testicular tuberculosis, followed by 4 months of continuous treatment with rifampicin and isoniazid was instituted. Orchidectomy is reserved only for those who present with abscess formation, unresponsive to medical management and diagnostic difficulty.
- TB testis mostly is associated with genitourinary TB or as a part of miliary TB
- Most of the testicular TB as a part of miliary TB is present with bilateral enlargement of the adrenal gland
- Isolated left adrenal gland enlargement may be due to anomalous left gonadal vessels
- Most patients respond to antituberculous treatment with rifampicin, isoniazid, pyrazinamide, and ethambutol
- The patient who fails to respond to antituberculous treatment needs left low inguinal orchidectomy as the treatment of choice.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]