Testicular mass with intracerebral lesions: malignancy or infection?

To cite: Prabhudesai SG, Sarkodieh JE, Mankad K. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/ bcr-2013-010186 DESCRIPTION A 59-year-old previously healthy man of Vietnamese origin presented to the urology one-stop-clinic with a 2-week history of painless left testicular swelling. Examination revealed a nontender, firm, lobulated testicular lump. Initial ultrasound findings were highly suspicious of a testicular neoplasm (figure 1). A staging CT revealed bilateral adrenal hypodense lesions (figure 2). In view of the suspicious clinical and imaging findings, the patient underwent a radical orchiectomy. Histology revealed multiple caseating granulomas with presence of acid-fast bacilli (AFB). A CT-guided adrenal biopsy also demonstrated multiple granulomas. No specimen revealed malignancy. Hence, a diagnosis of tuberculosis (TB) was confirmed. This was unusual as there was no history of cough, breathlessness, night sweats or weight loss. His chest radiograph was unremarkable. Sputum was negative for AFB and serum negative for HIV. In the postoperative period, the patient developed isolated left sixth nerve palsy. Gadolinium-enhanced MRI of the brain (figure 3) revealed multiple ringenhancing lesions. In view of positive histology results from the testis and adrenal gland, these were felt to represent tuberculomas. His symptoms improved following antituberculous treatment and a repeat MRI of the brain demonstrated significant regression of lesion burden. Isolated testicular TB without epididymal involvement is extremely uncommon. Testicular TB can masquerade as testicular malignancy. The adrenal glands are affected in up to 6% (invariably with bilateral involvement and hypoadrenalism), while central nervous system involvement is seen in approximately 5% of patients with TB. Recognition of its varying presentations is vital in the backdrop of a worldwide resurgence of TB.