A 63-year-old man was initially evaluated by Urology for right testicular swelling and pain for 3 months. As part of the workup, he underwent an ultrasound of the scrotum which showed 0.1 x 0.3 x 0.1 cm irregular hyperechoic focus with no shadowing or internal vascularity in the superior pole of the right testicle (Fig. 1, Fig. 2). Due to the concern for malignancy, the patient underwent an orchiectomy. Histopathology revealed acute and chronic necrotizing granulomatous changes. Upon further questioning, the patient denied any fevers, night sweats, weight loss or urinary symptoms. He did not have a history of BCG vaccination or prior history of tuberculosis infection. He did not report any contacts with tuberculosis and had never traveled outside the United States. He was not a healthcare worker, nor had he been in contact with incarcerated people. The only prominent finding in his past medical history was that he previously underwent a transurethral resection of a bladder tumor diagnosed 2 years prior. He had undergone transurethral resection of the bladder tumor (TUR-Bt) and received intravesical instillation with BCG 6 courses. CT head, chest and abdomen-pelvis were done and were unremarkable. Mycobacterium tuberculosis complex PCR of the sample was positive.
The patient was started on rifampicin, isoniazid, pyrazinamide and ethambutol and the sample was sent to the Texas Department of State Health Services for further identification. Spoligotyping of isolate combined with the VNTR-MIRU pattern (see below) was consistent with the Mycobacterium bovis-BCG strain. Sensitivity of this strain also later returned resistant to pyrazinamide. With these results, pyrazinamide was stopped but he continued on rifampin, isoniazid and ethambutol. The patient's condition gradually improved and has remained stable and asymptomatic to date.