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A6950 - Diagnostic Dilemma: A Newly Diagnosed Testicular Mass in a Young Male with Known Pulmonary TB
Author Block: S. Pourshahid1, G. Abrahamian1, K. Singh2, M. Korotun3, R. A. Lopez4; 1Internal Medicine Department at Queens Hospital center, Mount Sinai Health System, Jamaica, NY, United States, 2Pulmonology-Critical Care, New Hyde Park, NY, United States, 3Pulmonary and Critical Care, Northwell Health, New Hyde Park, NY, United States, 4Queens Hosp Ctr, Jamaica, NY, United States.
Introduction: A painless testicular mass in a young male has a high likelihood of malignancy. Here we present a case of a young male with known miliary TB who presented with a new painless testicular mass.
Clinical presentation: A 36 year old HIV negative man, recently emigrated from Guatemala, presented with daily fevers and weight loss of 10 lbs over the course of three weeks. Physical exam revealed hepatosplenomegaly. Genitourinary (GU) exam was deferred. Serum QuantiFERON was indeterminate and LFT were deranged. Chest CT was suggestive of miliary TB. Sputum for AFB were negative and a bronchoscopy with cultures showed pansensitive mycobacterium tuberculosis. ATT was initiated with improvement of liver function profile as well as defervescence. On admission day 8, the patient noted a testicular mass. On examination, a small well circumscribed right epidiymal mass was found. Ultrasound was suggestive for neoplasm. MRI with contrast of the pelvis showed hypointense T2 and iso-intense T1 signal intensity consistent with malignancy. Tumor markers including AFP, beta HCG and LDH were negative. A multidisciplinary case conference was called with Urology recommending immediate orchiectomy. However considering the overall clinical picture, a wait and watch policy was adopted with repeat imaging 2 weeks later. With no improvement, patient was taken to the OR where the mass was found to be fluctuant with purulent exudate . Orchiectomy was not performed .Intraoperative cultures showed TB. Patient dramatically improved and was discharged home with pulmonary follow-up.
Discussion: Less than 15% of extra pulmonary TB cases involve the GU tract. The most common site of GUTB in males is the epididymis. As the differential for a testicular mass includes neoplasms accurate and timely diagnosis is essential. History, imaging including ultrasound and MRI in addition to tumor markers are sometimes helpful in differentiating the etiology however neither imaging nor serum markers are accurate enough to replace the orchiectomy when there is high suspicion for testicular malignancy. USG generally shows diffuse heterogeneous hypoechoic enlarged epididymis or focal nodular hypoechoic lesion within. Preferentially the tail is involved while the head is spared. On MRI there is usually hypointense T2 signal intensity with variable T1signal intensity. In conclusion GU examination is often undermined in patients presenting with similar symptoms. Testicular TB is a rare presentation of TB infection which mimics primary testicular neoplasm. This leads to a diagnostic dilemma which is best solved by multidisciplinary case discussion with careful consideration to patient preference.