CASE REPORTS

 

Primary prostatic tuberculosis. Case report and bibliographic review

Tuberculosis prostática primaria. Presentación de un caso y revisión de literatura

 

 

Eliana López Baron, Diego Gómez-Arbelaez and Julio Alexander Díaz-Perez.

Grupo de Investigación en Patología Estructural. Funcional y Clínica de la Universidad Industrial de Santander. Bucaramanga. Colombia.
Fundación para el Avance de la Anatomía Patológica, Citológica y Clínica Molecular FAPCIM.

Correspondence

 

 

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SUMMARY

Objective: Primary prostatic tuberculosis is a very rare form of presentation of the tuberculous infection, which is generally caused by the M. tuberculosis, and which has shown an increase in incidence and prevalence, due to an increase of immunocompromised patients and the pandemic of the Syndrome of Acquired Immune Deficiency (AIDS).
We describe a case of primary prostatic tuberculosis attended at the Hospital Universitario de Santander, Colombia, and to perform a discussion about this topic.
Methods/results: 65 year old man who consulted with symptoms of frequency, dysuria and hesitancy, and 10 Kg weight loss in the last 6 months, without pulmonary symptoms and negative ELISA test for HIV. On physical examination the re was evidenceof the presence of a high volume, irregular and hard prostatic gland. That is why a prostatic Doppler ecography was performed showing a prostatic volume of 39 cm³, without sign of malignity. Biopsy of the prostatic gland showed multiple granulomas and the ZN staining was positive for mycobacteria. With these findings the diagnosis of primary prostatic tuberculosis was established, and treatment was carried out and now the patient is asymptomatic with no evidence of active tuberculosis.
Conclusions: Primary prostatic tuberculosis without history or evidence of commitment of the immune system is a very rare condition, nevertheless, it is particularly important to know it due to the progressive increase of its presentation and the possibility of a curative treatment to affected patients.

Key words: Primary prostatic tuberculosis. Urogenital tuberculosis. Granulomatous prostatitis. Tuberculosis. Prostate. (Source: MeSH).

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RESUMEN

Objetivo: La tuberculosis prostática primaria es una forma de presentación de la infección tuberculosa muy poco frecuente, es ocasionada generalmente por el M. Tuberculosis, la cual ha mostrado un aumento en su incidencia y prevalencia, debido al aumento de pacientes inmunodeficientes y la pandemia del Síndrome de Inmuno-Deficiencia Adquirida (SIDA). Describir un caso de tuberculosis prostática primaria atendido en el Hospital Universitario de Santander, Colombia, y realizar una discusión de este tema.
Método/resultado: Hombre de 65 años de edad quien consultó por polaquiuria, disuria y hesitancia. Con pérdida de 10 Kg. de peso en los últimos 6 meses, sin sintomatología pulmonar y prueba de ELISA negativa para VIH. En el examen físico se documentó la presencia de una próstata aumentada de volumen, irregular y dura. Por lo cual se realizo ecografía Doppler prostática que mostró un volumen prostático de 39 cm³, sin características indicadoras de malignidad. La biopsia por punción de la glándula mostró múltiples granulomas y la tinción de Ziel-Nielsen fue positiva para micobacterias. Con los anteriores hallazgos se realizó el diagnostico de tuberculosis prostática primaria, la cual fue tratada y actualmente el paciente se encuentra asintomático sin evidencia de enfermedad tuberculosa activa.
Conclusiones: La tuberculosis prostática primaria sin historia o evidencias de compromiso del sistema inmune, es una enfermedad muy poco frecuente, a pesar de lo anterior su conocimiento es de particular importancia debido al aumento progresivo de su presentación y a la posibilidad de realizar un tratamiento curativo a los pacientes afectados.

Palabras clave: Tuberculosis prostática primaria. Tuberculosis urogenital. Prostatitis granulomatosa. Tuberculosis. Próstata. (Fuente: DeCS).

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Introduction

Tuberculosis is an infectious disease caused by bacilli of the Mycobacterium complex, of which the most involved in its genesis is the M. tuberculosis, known as Koch's bacilli, in honor of its discoverer Robert Koch, other mycobacterium, more rare and heterogeneous are also involved in its origin such as the M. africanum, M. canetti y M Bovis (1). This disease can affect any organ of the human body, but in some of them its presentation is rare, these include the thyroid gland, myocardium, adrenal gland and prostate gland.

The prostate commitment by tuberculosis is the least frequent at genitourinary level, which can be developed more frequently secondary to a primary pulmonary tuberculosis or more rarely by the settling product of the sexual transmission of the mycobacterium (2,3). This disease has increased in frequency due to the pandemic of acquired immunodeficiency syndrome (AIDS) (2). In addition, the co-infection with HIV-AIDS brings forward atypical clinical presentations, which impede the diagnosis on simulating other genitourinary alterations such as the bacterial infection of the urinary tract or the benign prostate hyperplasia.

More over, these patients bring with them unusual clinical presentations of prostatic tuberculosis that are characterized by the presence of paucibacilar populations, which diminishes the sensibility of the conventional methods of diagnosis (2,3). Continuing there will be described a case of primary prostate tuberculosis attended in the University Hospital of Santander and there will be realized a constructed discussion on this topic.

 

Materials and methods

Clinical Case

A 65 year-old man presented with symptoms of frequency, dysuria and hesitancy. Additionally the patient informed the loss of 10 kg of weight in the last 6 months, without other symptoms. This patient had history of father with prostate carcinoma, additionally no history of immunodeficiency and ELISA's test for HIV negative in two opportunities. The physical examination revealed the presence of a prostate increased of volume, irregular and hard, without other alterations. It was realized, Prostate Specific Antigen (PSA) (7,17 ng/ml), creatinine (0,83 mg/dl), and urinalysis which reported over 10 erythrocytes/HPF. The prostate Doppler ultrasound scan showed slight increase of size, with a volume of 39 cm3 and an estimated weight of 34 grams, suitable contrast being observed between the peripheral and transitional zone, with homogeneous echogenicity and normal capsular edges, without abnormal zones of vascularization. Given the previous findings a sextant puncture biopsy was conducted, which revealed numerous granulomas consisting of epithelioid histiocytes, surrounded by a collar of lymphocytes and accompanied by Langhans type giant multinucleated cells; in some of them with caseification necrosis (Figures 1, 2). The Ziel-Nielsen staining was positive for mycobacterium. Alterations were not observed at the chest x-ray and thorax CT and microbiological evidence of mycobacterium at the sputum smear was not found, nor in the study of the bronco alveolar wash. With the previous finding there a diagnosis of primary prostate tuberculosis was realized and the patient was started on anti-tuberculous treatment with Rifampicin, Isoniazid and Streptomycin. After six weeks, the patient presented improvement of the symptomatology with only an episode of urinary obstruction at the beginning of the treatment. Nowadays the patient is asymptomatic without evidence of active tubercular disease.

 

 

Literature search strategy

A refining literature search was performed, using the MedLine database, across its Web portal PubMed, from January 1915 until April 2008, using initially the terms "Prostate tuberculosis" obtaining 153 original articles. Later it was added the term "Primary" to the previous terms, which showed 15 additional articles, for a whole of 168 articles, of which there were selected those considered relevant publications by the authors for the discussion of the topic. In addition, literature was taken from books and other publications.

 

Discussion

Prostatic tuberculosis, is one of the most infrequent forms of the tuberculous disease, which diagnosis needs the microbiological checking of the Micobacterium tuberculosis, that is realized generally by an invasive procedure, which has a high possibility of presenting a negative result, since it happens in any other type of extrapulmonar commitment, leading it to being a subdiagnosed and subtreated pathology. This disease affects principally individuals with some type of liability in the immune system as children, elders and immunosuppressed (1,2,3).

The tuberculosis is one of the most common infectious diseases, it is estimated that one third of the world's population are infected with Mycobacterium Tuberculosis, the active form of this disease appears in about 8.8 million persons every year, and it causes near 1.6 million annual deaths, which located the tuberculosis as the second cause of death for infectious diseases in the world after the AIDS (4,5). 95 % of the cases ocurr in developing countries as Colombia, with an annual incidence of 23 per 100.000 population(4). In addition, the co-infection of AIDS and tuberculosis is widely seen, it presents with some clinical and pathological characteristics that causes a particular behavior (2,6). The number of patients with tuberculosis of uncommon organs such as prostatic gland has been increasing in recent years, it is related to the increasing number of the immunosuppressed patients and to the creation of better programs for detection of tuberculosis (1,2,6).

Genitourinary tuberculosis has been documented among 8.7 and 15.5% of the cases of extrapulmonary tuberculosis (1.6), and the commitment of the prostate gland constitutes about 2.6% of genitourinary forms. Respiratory compromise in patients with genitourinary tuberculosis was only successfully documented in 37% of the patients (6), which is due to the difficulty in detecting quiescent and cured forms of the disease. The only study made in Colombia found that in the 102 patients studied with extrapulmonary tuberculosis, the genitourinary tuberculosis was the sixth presentation form of extrapulmonary compromise, with only 4 cases (3.84%), one of them witn involvement of the prostate gland (4).

The prostate can develop tuberculosis in two ways, the first is the secondary commitment of a primary infection in another organ, and the other form of is as a primary tuberculosis, which first reported case was made by Irvin S. Koll in the year 1915 (7), and which corresponds to the Mycobacterium's prostate infection without involvement of other organs, to date has documented some 42 cases of this type of disease, thus constituting a form of presentation very unusual (1,2,3,6,7). The secondary commitment from a primary focus of infection may occur and infection is transmitted to the prostate either by the downward spread from urinary tract or through hematogenous or lymphatic spread (1,7,8).

The primary presentation is produced by the mycobacterial infection through the urethra, it has been reported cases of infection by treatment with Bacillus Calmette Guerin (BCG) for superficial bladder cancer and other less frequent cases of sexual transmission (2.9), the patient reported in this article had no history of treatment with intravesical BCG, and it is assumed that the mode of infection was trough sexual transmission.

It should be borne in mind that tuberculous prostatitis is not the only inflammatory granulomatous disease that affects the prostate (8). There are other causes of granulomatous inflammation (Table 1), within which are the adenomatous prostatic hyperplasia, which is in the nature of foreign body granulomatous reaction due to damage of acini or ducts by intraluminal concretions or stones, and fungal infections such as South American blastomycosis, cryptococcosis, and coccidioidomycosis (8). The differentiation between different types of granulomatous prostatitis is of peculiar importance because it allows to establish the most appropriate form of treatment. Thus, the nonspecific granulomatous prostatitis resolves spontaneously by fibrosis, while the infectious granulomatous prostatitis requires specific antibiotic treatment (8).

 

The clinical findings in prostatic tuberculosis are often non-specific and generally demonstrate the local commitment; the symptoms most commonly found are the lower genitourinary tract obstruction and hematuria without pain (2.6). It can also be revealed signs of frequency and nocturia, which were present in the patient. As extra-prostatic manifestations can be observed weight loss, fever, anorexia, asthenia and perianal abscess, which as a form of presentation often suffers bacterial over-infection (9).

The findings on digital rectal examination are not specific or diagnose the disease, it has similar characteristics to other diseases such as benign prostatic hyperplasia and prostate cancer, the finding or indurated mass with firm and nodular irregular edge have been described (1,2,6,10), and is well correlated with the case. Similarly, imaging studies are not sensitive and do not easily distinguished with the carcinoma, especially when the urine tests have shown negative results to tuberculosis bacilli (6).

Doppler ultrasound, which is an unusual feature, generally shows increase of the prostate with irregular borders and diffuse hypoechoic lesions within the peripheral zone of the prostate, with occasional calcification and increased vascularity, especially during inflammatory prostatitis (6,11,12), which was not evident in the patient described here. Studies with CT show multiple lesions inside the prostate with irregular borders and low density (13). On making MRI large cystic masses are seen towards the periphery, with low-intensity radiated fields known as the "watermelon skin", which could be one of the few specific signs for prostatitis due to tuberculosis (6,12,13).

Serum PSA, have not shown considerable value in differentiating the prostate carcinoma and tuberculosis as the latter may cause the elevation of the same, and clinically mimicking cancer (6). However, studies have shown that this increase in the PSA is transient and decreases with the resolution of inflammation (6). Other laboratory tests useful in the definitive diagnosis of this condition and the discrimination of the possible differential diagnoses include urine analysis which is expected to be normal, although occasionally there is piuria without bacteriuria, this being more common when there is renal compromise, and a negative urine culture for other bacteria (13). Positive cultures for pyogenic organisms may lead to diagnostic errors (6).

Tuberculin skin test diagnosis is not considered due to the high prevalence of tuberculosis infection in our environment. Similar methods can be used as the amplification by polymerase chain reaction PCR, which showed a specificity of 98% and a sensitivity of 95%, plus the ability for rapid detection of mycobacteria in a sample of urine (14).

The diagnosis is usually made incidentally such as an histological finding after transurethral prostatectomy or in a punction prostatic biopsy (6,8,13). The demonstration of the presence of microorganisms in urine cultures or compromised tissue is needed for definitive diagnosis of genitourinary tuberculosis, but its diagnosis is often difficult because this type of spreading is a rare form of presentation, there is a difficult access to the sites of engagement as the prostate and the paucibacillary nature of the infection when it spreads beyond the lungs, which reduces the sensitivity and specificity of the tests, making difficult to detect acid-alcohol resistant bacilli by Ziel-Nielsen stain (8). In these cases it is necessary to keep the suspect when the histopathological study reveals prostatitis with epithelioid granulomas, Langhans type giant cells and caseification necrosis, and then make the final diagnosis depending on the response of the patient to the tuberculosis treatment (6,8).

Once diagnosed, the prostatic tuberculosis, is treated with the regimens for extrapulmonary tuberculosis with isoniazid, rifampin, pyrazinamide and streptomycin, a period of 6 months has proved to be sufficient because the adequate perfusion of these vascular tissues, the shortage of microorganisms at the site of infection, the high concentration of drugs in urine and its good penetration to the cavities formed in the infectious process, but there are those who prefer complete cycles of 9 months (15).

Shortened supervised treatment cures 95% of cases which prevents new infections and resistence in other patients, and is one of the more cost-effective (10 to $ 15 per patient) health interventions (5,15). Corticosteroid therapy has been recommended if there are restrictions or obstructions in the urinary tract and ureteral reimplantation is recommended if the blockage is not resolved after corticosteroid therapy (2).

In patients with genitourinary tuberculosis, surgery may be a treatment modality, especially given the suspicion of malignancy, refractory to antibiotic therapy, and in complicated cases with local tissue destruction, obstruction, abscesses, urinary tract infection or nephrolithiasis and pyelonephritis secondary, but it is important to clarify that this practice is becoming less important and the medical management is the first option (6).

The presentation of prostatic tuberculosis usually presents with a good prognosis, however, cause significant morbidity in affected patients. The most frequently seen complication is the development of infertility due to the many obstructions in the ejaculatory duct. Another of the complications, but less frequent, is the prostatic abscess, which is more commonly seen in patients with conditions of immunosuppression (1,2).

In conclusion it was presented and discussed a case of primary prostatic tuberculosis with no history or evidence of compromise of the immune system, a disease which despite being uncommon knowledge is of particular importance due to the progressive increase in its presentation and the possibility of a curative treatment to patients.

 

 

Correspondence:
Julio A. Díaz
Departamento de Patología
Universidad Industrial de Santander
Cra 32 No 32-10
Bucaramanga. (Colombia).
pat_uis@yahoo.com

Accepted for publication: April 21^th, 2008.

 

 

References and recomended readings (*of special interest, **of outstanding interest)

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**3. Richards MJ, Angus D. Possible sexual transmission of genitourinary tuberculosis. Int J Tuberc Lung Dis. 1998; 2(5): 439.        [ Links ]

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*5. WHO Report 2007. Global tuberculosis control, surveillance, planning, financing. Disponible en: www.who.int/tb/publications/global_report/2007/pdf/full.pdf        [ Links ]

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*12. Sánchez Sánchez E, Fernández González I, Ruiz Rubio JL, Herrero Payo A, Romero Cajigal I, Aramburu Gonzalez A, Antonio Moreno J, Berenguer Sánchez A. Transrectal echography in tuberculous prostatitis. Arch Esp Urol. 1994; 47(10): 1016-1018.        [ Links ]

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*15. Lee Y, Huang W, Huang J, Wang J, Yu C, Jiaan B, Huang J. Efficacy of chemotherapy for prostatic tuberculosis: a clinical and histologic follow-up study. Urology. 2001; 57(5): 872-877.        [ Links ]