Tubercular Orchitis in Young Adult Presenting as Testicular Torsion: An Infrequent Finding

    


    


    Figure 1: shows the gross appearance of the orchidectomy specimen. Figure1.b: the cut surface shows grey-white areas of firm consistency, with adjacent areas

of haemorrhage and necrosis, along with admixed viable testicular tissue. Figure1.c: H & E stained histopathological examination shows caseating epithelioid

histiocytic granulomas replacing the testicular parenchyma. Surrounding these granulomas, lymphocytes and Langhan’s giant cells can be seen. The inset shows

a multinucleated histiocytic giant cell at 400x. Figure1.d: shows areas of viable and non-viable testicular tissue due to torsion.

    

Discussion

Testicular torsion presents as an abrupt onset of unilateral scrotal pain associated with nausea, vomiting, lower abdominal pain, and inguinal pain. Patients frequently present with skin changes of the scrotum; however, scrotal lump and tenderness can also be seen. Clinical signs such as Prehn’s sign, Brenzel sign, and Ger’s sign help in making a clinical diagnosis [4-6]. The torsion of the testis affects predominantly neonates and adolescent populations. In neonates, torsion is due to a congenital anomaly of the processus vaginalis, which leads to extra-vaginal torsion, while in adolescents, bell-clapper deformity leads to intravaginal torsion (twisting of the spermatic cord within the tunica vaginalis) [3,7].

Other predisposing factors include environmental factors, preceding trauma, and familial inheritance. Cold weather and an overactive cremasteric reflex are two well-known environmental factors. Many studies have established the association between testicular torsion and weather [8-9]. The time from the onset of symptoms to reduction of torsion and the degree of cord twisting are the two most significant factors that determine the outcome in patients with torsion testis [10].

Another study done by Peeraully et al. on emergency scrotal exploration showed the rate of orchidectomy was significantly lower in patients admitted directly to the emergency department compared with those referred from primary health care centers or transferred from other hospitals. These studies highlighted the importance of time duration, which decides the outcome of the affected testis and the impact on patient life afterwards [11]. A study by Mukendi et al. revealed that the left-sided torsion was most frequently noted in individuals, less than 16 years of age, while the right-sided torsion mainly affected individuals, 16 years or older. This study also revealed that the winter season saw the highest number of hospitalizations, as compared to summers [9].

In our case, histo-morphological analysis revealed tubercular orchitis without epididymal involvement, with accompanying torsion of the right testis. Surprisingly, in the literature, there is no documented study about the association of torsion with tubercular orchitis. M. Cohen et al. found a link between an acute scrotum and concurrent involvement by a testicular tumour and contralateral torsion in a 27-year-old male [12]. In our patient, torsion of the testis with tubercular orchitis was affecting right side of testis, and the contralateral testis was normal.

Many studies reveal resemblance of testicular orchitis with that of a testicular mass. Differential diagnosis of malignancy is always kept in mind by clinicians. Only histopathology, can confirm the correct diagnosis. Hence, these studies signify the crucial role of a pathologist towards the correct diagnosis [13-14]. All age groups of both sexes are affected by tuberculosis, with a significant number occurring in males. The Indian population has a higher rate of tuberculosis than the Chinese population. The most frequent manifestation of extrapulmonary TB is urogenital TB, which is commonly seen in middle-aged males and accounts for 33.7%–45.5% of all extrapulmonary TB globally. The rare subtypes of urogenital tuberculosis include tuberculosis epididymitis, tubercular orchitis, and prostatic tuberculosis [15]. Generally, clinical symptoms of genitourinary tuberculosis manifest after 10-15 years of primary infection [13]. The epididymis is the most commonly affected part, involvement of which occur haematogenously from an infected prostate, and it can also affect the testis. However, isolated involvement of the testis is very uncommon. Edward et al. in their study, found involvement of the epididymis but could not find any primary testicular TB [16].

Early detection of testicular lesions improves the outcome with less intensive management. The constellation of clinical history, physical examination, radiological examination, and histopathological examination can help in making an early and correct diagnosis. Ultrasound guided fine needle aspiration cytology is an important out-patient tool that provides rapid and accurate diagnosis [13]. Ultrasonography alone doesn’t have much weight age as the pattern of torsion on sonography varies from case to case. However, a commonly described pattern of torsion is reduced testicular echogenicity. This pattern is not specific because patients with testicular trauma, tumors, and epididymo-orchitis may exhibit analogous findings [17].

Conclusion

There have been numerous reports of testicular torsion, but a case report of tubercular orchitis without involvement of the epididymis in a patient presenting clinically with torsion testis is exceedingly rare. To the best of our knowledge, a similar presentation of testicular torsion with tubercular orchitis has not been reported in the literature. Hence, this is a very rare incidental histopathological finding, and our case report adds to the literature a rare incidental finding of tubercular orchitis coexisting with torsion testis.

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