A 41-year-old Hispanic male with a history of diabetes and hypertension presented to a urology clinic at another institution for right testicular pain and swelling that progressed steadily over 1 month. He was treated for epididymitis with doxycycline but within 2 months he had increased pain and development of an indurated solid mass of the right testis that measured 25 x 19 x 60 mm. This led to a right inguinal orchiectomy.
The pathology report from that institution noted necrotizing granulomatous inflammation with a rare questionable acid-fast bacillus staining organism. All slides showed granulomatous disease. No slides showed any evidence of malignant disease. His right inguinal orchiectomy was without complications, but he was nonadherent to follow-up visits postoperatively.
Six months later, he developed opposite (left) testicular swelling and tenderness. He presented to Kern Medical Infectious Disease Clinic. Examination of the residual left testicle showed a chronic wound at the scrotal base. There was erythema and scrotal tenderness and a hard mass measuring 4.5 x 3 cm involving the entirety of the left testicle. He was treated for bacterial epididymitis with doxycycline without a salutary effect.
Records were obtained, the tissue block was requested and reexamined. Kern medical pathology review confirmed necrotizing granulomatous inflammation. No evidence of malignancy. No acid-fast organisms were identified.
Chest X-ray showed findings suspicious for lingular pneumonia. Urology was consulted. A new testicular, scrotal ultrasound was obtained and demonstrated an abnormal left testicular mass and extra-testicular heterogenous epididymal disease.
Studies were ordered for brucellosis, syphilis, gonorrhea, chlamydia, myeloperoxidase antibodies, and proteinase 3 antibodies. All were found negative. Urinalysis, urine AFB, and urine fungal cultures were also negative. The patient was not a candidate for the tuberculin skin test due to a prior positive reading years ago with negative chest X-ray at that time. Multiple efforts were made to acquire interferon-gamma release assays for Mycobacterium tuberculosis. Despite efforts to improve patient adherence, he remained inconsistently adherent to visits and laboratory orders. He attributed inconsistent adherence to socioeconomic challenges.
The clinical diagnosis of tuberculous epididymo-orchitis was made based on histopathologic suggestive evidence, past medical history, geographical history of endemic area, and failed antibiotic treatment. He was treated with the standard 4-drug antitubercular therapy and vitamin B6 for 6 months. His pain resolved within weeks and the mass itself resolved within months. Post-therapy, he was followed-up for 8 months and showed no evidence of active disease.