A 46-year-old male farmer, presented with a history of multiple, recurrent discharging scrotal ulcers over a period of three (3) years. He had had multiple wound debridements and dressings done, but the ulcers had recurred a few months after complete healing. The discharging wounds occurred after the formation and subsequent rupture of pustules.
He was otherwise healthy with no constitutional symptoms, significant comorbidities, and no previous history or contact history of TB. He had received the BCG vaccination during infancy. He was an averagely built male with normal general and systemic examination. Genitourinary examination revealed bilateral craggy, hard epididymes, an enlarged and tender right testis, and multiple, superficial, noninfected scrotal ulcers (Fig. 1A and B).
Ultrasonography showed bilateral normal-sized testes. The right epididymis was enlarged and thickened with a 1.4 x 1 cm sized hypoechoic lesion in relation to the head of the right epididymis and a 2 cm x 1.8 cm sized hypoechoic lesion in relation to the lower pole of the right testis. Internal vascularity was noted. The right testis was not identified separately from the lesion. Furthermore, there was a 1.3 x 0.8 cm sized hypoechoic lesion in the left testis and a 0.7 x 0.6 cm sized hypoechoic lesion in relation to the left epididymis.
His complete blood count and chest radiograph were normal. Erythrocyte sedimentation rate (ESR) was 90 mm/h, and the Mantoux was strongly positive with a diameter of 20 mm after 72 h. The urine full report (UFR) showed a field full of pus cells, and routine bacterial cultures were negative.
He underwent surgical exploration where the right epididymis was noted to be enlarged, irregular, and thickened with mild enlargement of the right testis with an irregular surface lesion, favoring chronic epididymo-orchitis (Fig. 2A and B). A right epididymal and testicular biopsy was performed, and histology revealed evidence of granulomatous inflammation with central caseous necrosis favoring mycobacterial TB infection. There was no evidence of intratubular germ cell neoplasia or malignancy. The Ziehl-Neelsen stain was negative for acid-fast bacilli. Pus from the scrotal discharge, the biopsy specimen, and the urine sent for TB culture returned negative.
He was started on category 1 antituberculosis therapy, that is, quadruple antimicrobial therapy for 2 months followed by dual therapy with rifampicin and isoniazid for 4 months, for which there was a good response with healing of the scrotal ulcers. He was compliant, and no significant adverse effects of treatment were noted. However, three (3) months into therapy, he presented with worsening lower urinary tract symptoms, strangury, and acute urinary retention. He required suprapubic catheterization, and subsequent retrograde urethrography revealed a bulbar urethral stricture for which he is under urological care.