Tuberculous prostatitis: a condition not confined to the immunocompromised

Abstract

A 72-year-old man from rural South Africa presented with a one-year history of lower urinary tract symptoms (LUTS) and intermittent right scrotal pain. His International Prostate Symptom Score (IPSS) (a questionnaire-based screening tool to quantify, track and manage the symptoms of BPH/LUTS) was 19, indicating moderately severe symptoms. 1 He denied any constitutional symptoms and there was no significant medical or surgical history. He had no known TB contacts nor any occupational risk factors to develop TB. He was not on corticosteroids. The general and systemic examination was unremarkable. The patient had mild right hemi-scrotal swelling with no skin changes or sinuses and no clearly definable mass on urogenital examination, and digital rectal examination (DRE) findings revealed a hard, nodular prostate. His prostate specific antigen (PSA) was 37.99 ug/L and urinalysis showed a sterile pyuria. A clinical suspicion of underlying 'prostate cancer' was formulated in light of the DRE and PSA, so a trans-rectal ultrasound guided (TRUS) prostate biopsy was performed. Histology showed extensive necrotising granulomatous inflammation suggestive of an active mycobacterial infection, although acid-fast bacilli (AFB) were not detected and PAS staining showed no fungal infection. (Figure 1 B-D). There were no pre-neoplastic or neoplastic features. Despite the absence of AFB on the slides assessed, the associated features and regional residence led to a working diagnosis of TB prostatitis and the patient was investigated accordingly. An HIV ELISA test was non-reactive. His chest