Eur Radiol (2004) 14:748–751 DOI 10.1007/s00330-003-1943-3
I N T E R P R E TAT I O N C O R N E R
© Springer-Verlag 2003
A.I. De Backer K.J. Mortelé J. De Roeck P.R. Ros B.L. De Keulenaer I.J. Vanschoubroeck P. Bomans
Tuberculous epididymitis associated with abdominal lymphadenopathy (2004:1b)
A.I. De Backer (✉) Department of Radiology, Algemeen Centrumziekenhuis Antwerpen, Campus Stuivenberg, Lange Beeldekensstraat 267, 2060 Antwerpen, Belgium E-mail:
[email protected] Tel.: +32-3-2177636 Fax: +32-3-2177101
B.L. De Keulenaer Intensive Care Unit, Royal Darwin Hospital, Rocklands, 0810 Tiwi, Northern Territory, Australia
K.J. Mortelé · P.R. Ros Department of Radiology, Abdominal Imaging and Intervention, Brigham and Women’s Hospital, 75 Francis Street, Boston, Massachusetts, USA J. De Roeck Department of Radiology, A.Z. St-Elisabeth, Nederrij 133, 2200 Herentals, Belgium B.L. De Keulenaer · I.J. Vanschoubroeck P. Bomans Department of Internal Medicine, Algemeen Centrumziekenhuis Antwerpen, Campus Stuivenberg, Lange Beeldekensstraat 267, 2060 Antwerpen, Belgium
Abstract Although the predominant form of tuberculosis is pulmonary disease, an increasing number of cases with extra-pulmonary involvement have been reported. The diagnosis of extra-pulmonary tuberculosis is often difficult because of its protean clinical manifestations and non-specific laboratory findings. Abdominal lymph node involvement may be present alone or in combination with involvement of the gastrointes-
Introduction Tuberculosis continues to be a major cause of morbidity and mortality in developing countries. Moreover, its incidence is also increasing in developed countries, mainly in immigrants and in patients with AIDS. Furthermore, poor living conditions with homelessness, unemployment, and inadequate access to health care may explain its steadily increasing incidence in big cities and their suburbs [1, 2].
Case report A 28-year-old Indian immigrant was admitted to our hospital because of dysuria and scrotal pain. Subsequent US of the scrotum revealed a heterogeneous, diffusely swollen, and hypoechoic left epi-
tinal tract, peritoneum, and solid viscera. Tuberculous epididymitis occurs sporadically and represents a specific secondary subacute or chronic inflammatory process involving the epididymis. We present the imaging findings in a patient with tuberculous epididymitis associated with abdominal tuberculous lymphadenopathy. Keywords Tuberculosis · Epididymitis · Lymphadenopathy · Ultrasound · Computed tomography · Magnetic resonance imaging
didymis (Fig. 1). No associated hydrocele was present. The right epididymis and both testes were normal. A diagnosis of epididymitis was made and the patient was treated with oral antibiotics; however, despite prolonged treatment with antibiotics for 1 month, clinical symptoms and US abnormalities persisted, and the patient developed epigastric pain. Ultrasound of the abdomen was performed and showed multiple, well-delineated hypoechoic masses measuring between 2 and 4 cm in the upper abdomen. Computed tomography of the abdomen after intravenous administration of iodinated contrast medium confirmed these lesions located in the peripancreatic region, the porta hepatis, and splenic hilum. The masses showed a peripheral, thin, enhancing rim that appeared with centrally low attenuation (Fig. 2). These finding were highly suggestive for lymphadenopathy. On MRI, the enlarged lymph nodes appeared hypointense on T1-weighted images and hyperintense on T2-weighted images, when compared with abdominal wall muscle. A slight peripheral rim, hyperintense on T1-weighted images and hypointense on T2weighted images, was noted (Fig. 3). Although the lymphadenopathy encased major vessels and the common bile duct, no definite ev-
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Fig. 1 Ultrasound of the scrotum in a 28-year-old Indian immigrant with scrotal pain and dysuria shows a diffusely swollen and hypoechoic left epididymis Fig. 2 Tuberculous lymphadenopathy. Computed tomography of the abdomen after intravenous and oral contrast material administration shows multiple hypodense lesions with peripheral enhancement in the porta hepatis, peripancreatic region, and in the splenic hilum Fig. 3a–c The MRI findings. a Axial gradient-echo T1-weighted image shows tuberculous lymphadenopathy as hypointense enlarged lymph node. A slight peripheral hyperintense rim is barely visible. b Axial single-shot fast spin-echo T2-weighted image shows these lesions as hyperintense with a peripheral hypointense rim. c Coronal single-shot fast spin-echo T2-weighted image shows bulky lymhadenopathy in the porta hepatis without obstruction of the common bile duct
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idence of obstruction or invasion was found. Chest radiograph was unremarkable. Laboratory tests, tumor markers, and serological markers for HIV, hepatitis B and C, and hydatid disease were negative. Cytology of a small amount of purulent fluid, following fineneedle aspiration using US guidance of the lymphadenopathy in the peripancreatic region, was performed. Smears showed necrotic material. Granulomas were not found. Ziehl-Neelsen staining for acidfast bacilli was negative. Subsequently, a diagnostic laparoscopy was performed. Multiple necrotic, enlarged lymph nodes adhering to the pancreas, the porta hepatis, and splenic hilum were found. An excisional biopsy of peripancreatic lymph nodes was performed. Cross-sectional slicing of the specimen showed that liquefactive substances in the center of the enlarged lymph nodes were surrounded by inflammatory lymphatic tissue. Degenerating granulomas, viable epithelioid cell granulomas, and Langerhans’ giant cells were seen on microscopic examination. Acid-fast bacilli were found occasionally by Ziehl-Neelsen staining. These findings allowed diagnosis of tuberculous lymphadenopathy and made the presumptive diagnosis of tuberculous epididymitis very likely. Antituberculous treatment was started with ethambutol, isoniazid, rifampin, and pyrazinamide, and the patient became asymptomatic. Follow-up abdominal CT and MRI showed disappearance of the lymphadenopathy and scrotal US showed normalization in size of left epididymis.
Discussion Isolated tuberculous epididymitis without upper urinary tract infection is thought to be of hematogenous origin and occurs very rarely [3]. Most often, involvement of the scrotal contents is due to downward spread of renal tuberculosis and the consequent antegrade seeding of viable tubercle bacilli downstream. Epididymal involvement may occur after retrograde seeding of viable bacilli from the prostate or seminal vesicles via the vasal lumen itself or the perivasal lymphatics [4, 5]. Unilateral or bilateral epididymal involvement may occur. In the early stages, the testis is usually spared. In the more advanced stages, testicular involvement caused by direct extension of a tuberculous abscess in the epididymis may be seen [3, 4]; the latter may occur if therapy is not appropriate. Tuberculous lymphadenopathy is the most common manifestation of abdominal tuberculosis. It may occur as an isolated manifestation without other evidence of abdominal involvement; however, associated involvement of the gastrointestinal tract, peritoneum, and solid viscera is often seen. Multiple lymph node groups, especially the mesenteric and peripancreatic ones, are mostly involved simultaneously while isolated retroperitoneal lymphadenopathy is an uncommon finding [1]. Although coexistence of pulmonary tuberculosis may be suggestive of associated abdominal tuberculosis, only 15% of cases of abdominal tuberculosis have evidence of associated pulmonary disease [6]. To the best of our knowledge, the combination of primary tuberculous epididymitis with isolated tuberculous abdominal lymphadenopathy has never been described. Although bilateral involvement in tuberculous epididymitis was the rule in the past, the disease is presently primarily unilateral [4]. The disease usually starts in the tail portion of the epididymis, either because it has a
greater blood supply compared with other parts of the epididymis or because it is the first portion involved by urinary reflux along the vas deferens [6]. Ultrasound examination shows enlargement of the tail of the epididymis, which is diffusely hypoechoic, and thickening of the testicular sheaths. These US findings are, however, nonspecific, and differentiation between specific and nonspecific inflammation is not possible [4]. At a later stage, the inflammatory process usually involves both the head and tail of the epididymis, but not the body (“bipolar” form). However, diffuse involvement, as seen in our case, has also been reported. In these cases, US examination may show a diffusely enlarged and hypoechoic epididymis or a nodular “complex mass”, hypoechoic with poor internal echoes and multiple septations. Thickening of the sheaths, especially the vaginal one, is usually seen and a characteristic hydrocele with septations may be present [3, 4]. The marked sonographic heterogeneity may be explained by the variety of pathological components, including caseation necrosis, fibrosis, and granulation. If calcification or central necrosis is present, the lesion may have a more heterogeneous echotexture. In more advanced cases, a chronic draining sinus resulting from caseous abscess formation may reach the scrotal skin. If present, this finding should be regarded as pathognomonic for a tuberculous origin until proven otherwise [4, 8]. Epididymo-orchitis occurs when inflammation of the epididymis directly extends into the testicular parenchyma. This is characterized on US by the presence of diffuse enlargement of a hypoechoic testis, an ill-defined or well-demarcated hypoechoic lesion, or multiple small hypoechoic nodules. If an intratesticular hypoechoic lesion is present, differentiation from a tumor may be impossible, and early surgical exploration may be required if the lesion does not respond rapidly to anti-tuberculous chemotherapy [9]. Tuberculous lymphandenopathy is easily detected both on CT and MRI. The nodes are usually multiple and large, measuring typically less than 4.0 cm in diameter due to their self-limiting growth; however, a wide spectrum of patterns has been described ranging from increased number of normal-sized nodes to massive nodal conglomerates [10]. On MRI, tuberculous lymphadenopathy may show a variety of signal intensities in relation to abdominal wall muscle: iso- or hypointense on T1-weighted images and hypo- or hyperintense on T2-weighted images. A peripheral rim of increased or decreased signal intensity may be present [11]. Tuberculous lymphadenopathy may show a variety of patterns of enhancement with intravenous contrast agents, even within the same nodal group, possibly related to the different stages of the pathological process [12]. Enhancement patterns described include: peripheral enhancement visible as a uniform, thin, completely enhancing rim; a thick irregular, complete or incomplete, peripheral rim; and conglomerated group of nodes showing peripheral and
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central areas of enhancement. A heterogeneous enhancement and, less frequently, homogeneous enhancement or no enhancement, may also be seen [12]. Pathological findings from surgically obtained specimens of tuberculous lymphadenopathy indicate that caseation or liquefaction at the center of the enlarged lymph nodes, presumably resulting from insufficient blood supply, correlates with the low attenuation/signal intensity on CT/MRI. The peripheral inflammatory lymphatic tissue, on the other hand, has a higher attenuation/signal intensity on enhanced CT/MRI resulting from the preserved blood supply. The peripheral rim-enhancement pattern has been reported to occur most frequently in tuberculous lymphadenopathy. This finding, however, is not pathognomonic, because a similar pattern may be seen in malignant aden-
opathy, especially in metastases from testicular tumors, primary head and neck squamous cell carcinoma, in benign conditions such as Whipple’s and Crohn’s disease, and in pyogenic infection [10, 12]. Involved lymph nodes may occasionally show calcification, and although this finding is not specific, it is highly suggestive for tuberculosis. As shown in our case, despite considerable bulk of adenopathy, tuberculous lymph node enlargement is usually not responsible for invasion or obstruction of the common bile duct, blood vessels, and urinary or gastrointestinal tracts. In conclusion, in a patient with unilateral epididymitis resistant to antibiotic therapy, associated with abdominal lymphadenopathy, and characterized by a peripheral rim enhancement, tuberculosis has to be excluded.
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5. Riehle RA, Jayaraman K (1982) Tuberculosis of the testis. Urology 20:43–46 6. Akhan O, Pringot J (2002) Imaging of abdominal tuberculosis. Eur Radiol 12:312–323 7. Kim SH, Pollack HM, Cho KS et al. (1993) Tuberculous epididymitis and epididymo-orchitis: sonographic findings. J Urol 150:81–84 8. Chung T, Harris RD (1991) Tuberculous epididymo-orchitis: sonographic findings. J Clin Ultrasound 19:367–369 9. Dempsey J, Brooks J, Scott RL (1992) Testicular pseudotumor caused by Mycobacterium bovis epididymitis. J Clin Ultrasound 20:200–203
10. Leder RA, Low VH (1995) Tuberculosis of the abdomen. Radiol Clin North Am 33:691–698 11. Kim SY, Kim MJ, Chung JJ, Lee JT, Yoo HS (2000) Abdominal tuberculous lymphadenopathy: MR imaging findings. Abdom Imaging 25:627–632 12. Pombo F, Rodriguez E, Mato J et al. (1992) Patterns of contrast enhancement of tuberculous lymph nodes demonstrated by computed tomography. Clin Radiol 46:13–17
Precisely correct answers were received by the closing date from: N. Chidambaranathan, Chennai, India James D. Birchall, Nottingham, UK Erkki Svedstrüm, Turku, Finland Nevzat Karabulut, Denizl, Turkey Filip Vanhoenacker, Duffel, Belgium
N.B.S. Mani, Nassau, Bahamas Manabu Minami, Tokyo, Japan Luis Tata, Amadora, Portugal Mark Towers, County Meath, Ireland Ercan Kocakoc, Elazig, Turkey
Interpretation Corner 2003 Winners Following the introduction of this section in the journal in 2003, it has been gratifying to see ever-increasing interest. The 12th case of 2003 saw an unprecedented number of correct answers. During the year, three correspondents supplied significantly more correct answers than the others. They were: – Dr Filip Vanhoenacker of Duffer-Mechelen, Belgium, who supplied correct or virtually correct answers in 6/12 cases.
– Dr Ercan Kocakoc of Elazig, Turkey and – Dr Manabu Minami of Tokyo, Japan, who were correct in 3–4 cases each. A certificate to this effect will be sent to them to congratulate them on their considerable diagnostic skills. The Editors
