A 23-year-old male from Cameroon presented with acute-onset, right-sided scrotal pain and swelling while in the US for military training. He denied current or prior sexual activity, associated penile discharge, hematuria, fevers night sweats, weight loss, or cough. Urinalysis revealed pyuria, follow-on culture was not performed, and urine nucleic acid amplification testing (NAAT) was negative for Neisseria gonorrhoeae and Chlamydia trachomatis. He was diagnosed with acute epididymitis and treated with ceftriaxone and doxycycline. His symptoms improved, only to recur 6 weeks later, prompting a repeat ultrasound that revealed persistent epididymitis. Repeat urinalysis (no culture) and gonorrhea and chlamydia NAAT were negative. He was given an empiric 30-day course of ciprofloxacin, which improved the pain, but the swelling persisted.
Five months after his initial evaluation, he returned with another recurrence of symptoms. Physical exam again revealed prominent right-sided scrotal swelling and tenderness. An ultrasound demonstrated right-sided epididymitis with possible necrosis, increasing complexity of the associated hydrocele, and new concerns for a focal scrotal abscess. This was further evaluated with a contrasted computed tomography (CT) of the chest, abdomen, and pelvis, which revealed a complex right-sided scrotal fluid collection (Figure 1) in addition to an enlarged and heterogeneous prostate, an enlarged juxtaesophageal lymph node, and right lung apical nodular scarring. Although TB was considered in the differential diagnosis, a unilateral orchiectomy was performed, as malignancy was also high on the differential given his age.
Grossly, the epididymis was enlarged (6.0 x 1.7 x 1.5 cm; Figure 2), with caseating necrosis and miliary deposits within the testicle and epididymis (Figure 3). There was an accompanying large scrotal abscess. The histologic sections showed diffuse necrotizing granulomas, with giant cell formation in the scrotum, testis, and epididymis (Figure 4). The testicular parenchyma stained positive for acid-fast bacilli (AFB), and a surgical-scrotal aspirate NAAT using the GeneXpert MTB/RIF assay (Cepheid, Sunnyvale, CA) was positive for Mycobacterium tuberculosis (no rifampin resistance was detected). Urine AFB stain and urine NAAT were negative for TB; ultimately, the urine AFB culture was positive for TB. Despite a normal chest X-ray and reported lack of pulmonary symptoms, his sputum was also positive for TB by stain, NAAT, and culture. Antimicrobial susceptibility testing revealed no resistance to first-line agents. An immunoassay for human immunodeficiency virus (HIV) was nonreactive.
He was started on rifampin, isoniazid, pyrazinamide, and ethambutol. However, due to the development of hepatotoxicity 12 days into therapy without evidence of viral hepatitis, he was transitioned to ethambutol, levofloxacin, and intravenous amikacin. On treatment day 15, his sputum smears converted to negative. After resolution of his drug-induced liver injury on treatment day 26, amikacin was discontinued in favor of rifampin, and he was recalled to Cameroon soon thereafter on an all-oral, three-drug regimen.