A 45-year-old car spare parts dealer presented to the Abnira medical centre with a five-year history of left scrotal swelling and a two-week history of left scrotal ulcer. The swelling, which had being increasing in size, regressed some months before presentation and became hardened with ulcerated foci some weeks after. There was a history of contact with persons with pulmonary TB in the past, for over a year.
On examination, he was not in obvious painful distress, not pale, anicteric, afebrile, not dehydrated, and had no obvious weight loss. His pulse rate was 80/minute and regular with full volume, and his blood pressure was 120/80 mmHg. Heart sounds were 1st and 2nd only, his respiratory rate was 14 cycles per minute and both lung fields were clear. The abdomen was full, moved with respiration with no palpably enlarged abdominal mass, and kidneys were not ballotable.
The right scrotum was normal whereas the left was swollen with two foci of discharging ulcer, with a proximal focus of 3 cm x 2 cm and a distal focus of 2 cm x 1 cm. The foci were approximately 2 cm apart. On palpation, the area was found to be non-tender, hard, able to go above the mass, not attached to the overlying skin, and not transilluminable.
The laboratory data showed an elevated erythrocyte sedimentation rate (ESR) of 40 mmfall/hr. Full blood count (FBC) showed a hemoglobin (Hb) of 12.3 g/dL, a white blood cell count (WBC) of 3,250 cells/mm,3 and platelets of 259000 with a WBC differential showing 28 neutrophils, 69 lymphocytes, 1 monocyte, 2 eosinophils, and 0 basophils. Blood film showed reactive lymphocytes +++, toxic granulation ++, macrocytes ++, microcyte +, neutropenia, lymphocytosis, hypochromasia, and platelets to be adequate and normal. Swab microscopy culture and sensitivity (M/C/S) yielded a growth of the staphylococcus species after a 24-hour incubation at 37  C, sensitive to gentamicin, levofloxacin and sparfloxacin. Chest x-ray, spinal x-ray, urea, electrolyte, creatinine and liver function tests were found to be normal. Retroviral screening and venereal Disease Research Laboratory (VDRL) tests were non-reactive.
An assessment of left testicular tumor was made and the patient was prepared for left orchidectomy (after obtaining an informed consent). At surgery, a tract was found connecting the proximal and distal ulcer foci. Fistulectomy and Orchidectomy.
The histological findings of the excised left testis were: macroscopic description (A): SCO soft-to-firm testicular tissue measuring 7 x 5 x 3 cm and weighing 57 g, with a cut section showing a mass of 4 cm diameter and 3 k. (B): SCO a skin tissue measuring 3 x 3 x 2 cm and weighing 8 g, with a cut section showing a grayish surface.
Microscopy: Testicular tissue showed stratified squamous within the stroma, several granuloma and extensive caseous necrosis. The histological diagnosis was tuberculosis.
Anti-tuberculosis chemotherapy was subsequently initiated. Three months after surgery, recurrence has not been found.