GLOBAL  JOURNAL  OF  MEDICINE  AND  PUBLIC  HEALTH      

    1   www.gjmedph.org  Vol.  3,  No.  4  2014                                                                                                                                                                                                                                                                                                                                                        ISSN#-­‐  2277-­‐9604  

 

Prostatic  abscess  by  ‘the  great  imitator’  in  a  HIV  patient  -­‐  a  case  report.    Pandurangan  Thilakavathy1*,  R.M.Sathish  Kumar  2  ,  Anand    B.  Janagond  3  ,  G.S.Vijay  Kumar  4  

   ABSTRACT  Tuberculosis   (TB)   of   prostate   is   a   very   rare   condition.  We   present   a   case   of  primary   prostatic   tubercular   abscess   in   a   young   HIV   seropositive   patient.  There   was   no   classical   clinical   presentation   of   tuberculosis   in   the   patient.  Microbiological   analysis   of   aspirated   pus   from   prostatic   abscess   showed  plenty  of   inflammatory  cells   in  Gram  stained  direct   smear  and  Ziehl  Neelsen  staining   showed   acid   fast   bacilli.   Retrospective   detailed   interrogation   of   the  patient   and   further   investigations   aided   in   the   diagnosis   of   prostatic  tubercular  abscess.    Keywords:  Tuberculosis,  prostatic  abscess,  acid  fast  bacilli    INTRODUCTION  Genitourinary   tuberculosis   (GUTB)   is   the   second  commonest  extra  pulmonary   tuberculosis.  Thorough  knowledge,  epidemiology  of   tuberculosis   (TB)   in   the  region  and  a  strong  clinical  suspicion  is  very  essential  for   early   diagnosis.   India   and   China   together   have  more  than  50%  of  global  TB  cases;  many  of  these  are  multidrug   resistant   (MDR)   cases.   About   4%   of   new  and  20%  of   old  TB   cases   are   found   to   be  MDR-­‐TBs.  TB  is  also  known  as  ‘the  great  imitator’  because  of  its  varied   clinical   presentation.   GUTB   may   not   present  with   classical   presentation,   majority   of   cases   may  have  only   sterile   acidic  pyuria.  Only  20%  cases  have  detectable   primary   focus.   HIV   infected   persons   are  more  vulnerable  to  GUTB  and  the  rate  varies  from  15  –  50%.  Mycobacterium  tuberculosis  (MTB)  is  older  to  humans  and   it   has   diverse   adaptability.  Despite   the   effort   of  World   health   organization   (WHO)   and   the   entire  world,   TB   control   has   not   been   successful.  With   the  emergence   of   unholy   nexus   between   TB   and   HIV,  newer   problems   have   cropped   in   the   presentation,  diagnosis   and   management   of   TB.   In   recent   times  there   has   been   a   spurt   in   the   occurrence   of  extrapulmonary  TB.  10  –  14  %  of  extrapulmonary  TB  cases   involve   genitourinary   system.   [1]   Primary  

prostatic   tubercular  abscess  without  any  predisposing  factors   occurring   in  young   patients   is   increasing.   Non   specific  presentation  and  absence  of  a  classical  sign  has  made  clinical   diagnosis   of   prostatic   abscess   impossible.  Modern   radiological   diagnostic   methods   like  transrectal   ultrasound   (TRUS)   and   computed  tomography   (CT)   have   facilitated   the   diagnosis   of  prostatic   abscess.   [2]   The   double   edged   sword   of  HIV-­‐  TB  has  complicated  therapeutics  of  tuberculosis  including   prostatic   abscess   due   to   emergence   of  Multi  drug  resistance  in  MTB  and  HIV  strains.    CASE  REPORT  A  37  years  old  male  patient  presented  with  history  of  intermittent   urinary   retention   for   six   months   and  burning   micturition   since   a   fortnight   was   evaluated  by   the   urologist.   General   physical   examination   was  found   normal.   Routine   haematological   and  biochemical   investigation   parameters   were   within  normal   limits,   except   marginally   elevated   ESR   (25  mm).   X-­‐ray   chest   was   normal.   Digital   per   rectal  examination   showed   nodular   prostate   and   boggy  right   lobe.   Ultrasonography   (USG)   of   the   abdomen  

GJMEDPH  2014;  Vol.  3,  issue  4    *Corresponding  author:  thilaka_doctor@yahoo.co.in    1  Assistant  Professor  VMCH   &   RI,   Department   of  Microbiology,  Madurai,  India  1  Assistant  Professor  VMCH   &   RI,   Department   of  Urology,  Madurai,  India  3  Associate  Professor  VMCH   &   RI,   Department   of  Microbiology,  Madurai,  India  4  Professor  &  Head  Assistant  Professor  VMCH   &   RI,   Department   of  Microbiology,  Madurai,  India    Conflict  of  Interest—none      Funding—none        

 

    2   www.gjmedph.org  Vol.  3,  No.  4  2014                                                                                                                                                                                                                                                                                                                                                        ISSN#-­‐  2277-­‐9604  

 

Case  report  

revealed  a  hypoechoic   lesion   in  the  posterior   lobe  of  prostate   suggestive   of   prostatitis   with   abscess.   CT  scan   abdomen   showed   hyperdense,   enlarged   lymph  nodes   having   central   necrosis   in   the   periportal,  peripancreatic,   paraaortic,   aortocaval   and   retrocaval  regions.   Prostate   was   enlarged   and   there   were  irregular   hypodense   areas   involving   right   and   left  lobes.   There   was   indenting   of   the   anterior   wall   of  rectum.   CT   scan   findings   also   favoured   prostatitis  with   abscess   (fig   -­‐1).   TRUS   guided   aspiration   was  done   and   about     5  ml   of   thick   blood  mixed  pus  was  drained,   prostate   appeared   heterogenous   with  increased  vascularity.  This  aspirated  fluid  was  sent  to  microbiology   laboratory   for   bacteriological  examination.   Microscopic   examination   of   Gram  stained  smear   showed  plenty  of  polymorphs;  but  no  bacteria   were   found.   A   Ziehl   Neelsen   (ZN)   stained  smear  examination  showed  plenty  of  acid  fast  bacilli.  Aerobic   culture  of   the   fluid  was   sterile   at   the  end  of  48  hrs.      

 

TRUS   guided   prostatic   tissue   biopsy   was   done,  histopathological   diagnosis   of   the   tissue   was  granulomatous   prostatitis   possibly   tuberculosis   (fig-­‐2).  CT  scan  screening  of  whole  body  was  done  to  find  out   the   primary   focus.   There   was   no   evidence   of  primary   tuberculosis   elsewhere   in   the   body.   By   this  we   confirmed   the   primary   prostatic   tubercular  abscess   of   the   case.   Patient’s   age,   occupation   and  AFB  positivity  led  to  suspicion  of  possible  co-­‐existing  HIV   infection.   As   per   NACO   guidelines,   he   was  counselled   and   with   his   written   consent,   blood   was  drawn   and   tested   for   HIV   seropositivity.   He   was  found  reactive  for  HIV-­‐1.  During  post  test  counselling  the  patient  was  told  about  TB  –HIV  and  the  schedule  of  treatment.  Patient  has  been  referred  to  HAART  &  RNTCP  centre  for  further  treatment.    

 Figure  2  HPE  :  showing    prostatic  tissue  with    focal  collections  of    epitheloid  cells  forming  granulomas  

surrounded  by    lymphocytes  and  fibroblasts

Figure  1  CT  Image  showing  abscess    DISCUSSION  Prostatic   tubercular   abscess   is   an   unusual,   but  curable   infectious   disease.   In   an   Indian   study  analysing  48  prostatic  abscesses  only  one  was  a  case  of   tubercular   aetiology.   [3]   Majority   of   tubercular  prostatitis   cases   are   asymptomatic.   Prolonged  duration  of  local  symptoms  and  a  normal  WBC  count  confuses  the  diagnosis  of  tubercular  abscess.  Clinical  presentation   of   prostatic   abscess   has   undergone   a  sea  change  in  this  antibiotic  era.  Tubercular  prostatic  

abscess   diagnosis   needs   a   high   degree   of   suspicion,  proper   processing   of   the   material   and   thorough  scanning   of   the   smear   for   microscopic   detection   of  AFB.   TB   Prostate   is   always   secondary   to   pulmonary  or   renal   TB.   Spread   from   primary   foci   is   by  haematogenous   route.     Primary   focus   may   not   be  detected  in  many  of  the  extra  pulmonary  tuberculosis  cases.     It   could   be   due   to   reactivation   of   a   primary  focus   in   persons   with   remote   history   of   TB.   [4]  Seeding   of   prostate   may   also   occur   from   a  microscopic  focus  elsewhere   in  the  body,  which  may  not   be   detected.     Prostatic   tubercular   abscess   is  

 

    3   www.gjmedph.org  Vol.  3,  No.  4  2014                                                                                                                                                                                                                                                                                                                                                        ISSN#-­‐  2277-­‐9604  

 

Case  report  

known   to   occur   as   a   post   treatment   complication   in  patients  with  non   invasive  bladder  cancer  cases  who  were   treated   with   intravesicle   BCG.   [5]   Majority   of  prostatic   tuberculosis   cases   may   be   quiescent,  without  any  obvious  signs  and  symptoms.  Retention  of   urine   may   be   the   only   presenting   complaint   in  some  cases.  Our  patient  also  had  intermittent  urinary  retention,   but   he   did   not   have   any   other   TB   related  clinical  features.  Exact  mechanism  of  pathogenesis  of  tubercular   prostatic   abscess   in   HIV   patients   is   not  clearly  known.    TB   Prostate   is   more   often   diagnosed   by   urologists  during   transurethral   resection.   Many   patients   have  lower   urinary   tract   obstruction,   suggesting   urinary  stasis  in  the  pathogenesis  of  prostatic  abscess.  Delay  in   diagnosis   and   initiation   of   proper   treatment  may  result   in  spread  to  adjacent  tissue  or  organs   forming  sinuses   or   fistulae   to   the   perineum   or   rectum,  perivesical  space,  as  well  as   into  the  peritoneum  and  

bladder.   Antitubercular   therapy   and   ultrasound  guided   drainage   of   the   abscess  will   completely   cure    prostatic   tubercular   abscess.   Our   patient   has   been  referred   to   HAART   &   RNTCP   centre   for   further  treatment.    CONCLUSION  It   is   important   to   suspect   tubercular   abscess   in   a  patient  with  history  of  urinary  voiding  problems  and  thorough   examination   is   vital   to   rule   out   TB.  Aspiration   of   the   fluid   and   submitting   for   detailed  laboratory  examination  should  not  be  neglected.    ACKNOWLEDGEMENTS  M.Mariappan,   assistant  professor   at   the  department  of  radiodiagnosis,  VMCH&RI.  K.Yegumuthu   assistant   professor   at   the  department  of  pathology,  VMCH&RI.    

 REFERENCES  

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2.  Cytron  S,  Weinberger  M,  Pitlik  SD,  Servadio  C:   Value   of   transrectal   ultrasonography   for  diagnosis  and  treatment  of  prostatic  abscess.  Urology.  1988;  32:  454-­‐8.  

3. Jigish   B   Vyas,  Sanika   A   Ganpule,  Arvind   P  Ganpule,  Ravindra   B   Sabnis,  and  Mahesh   R  Desai     Transrectal   ultrasound-­‐guided  

aspiration   in   the   management   of   prostatic  abscess:   A   single-­‐center   experience   Indian   J  Radiol  Imaging.  2013  Jul-­‐Sep;  23(3):  253–257.  

4. Ludwig   M,   Velcovsky   HG,   Weidner   W.  Tuberculous   epididymo-­‐orchitis   and  prostatitis:   a   case   report.  Andrologia.  2008;40:  81–83.    

5. Seung   Whan   Doo,   Jae   Heon   Kim,   and   Yun  Seob  Song;  A  Case  of  Tuberculous  Prostatitis  with   Abscess.   World   J.   Mens   health.   Aug  2012;   30   (2):   (138   –   140).