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EDITORIAL COMMENTARY
Year : 2023 | Volume
: 69
| Issue : 4 | Page : 194-195
Tuberculosis: A masquerader and master of mirages!
A Gopan
Correspondence Address:
Dr. A Gopan
Department of Hepatology, Sir H. N. Reliance Foundation Hospital and Research Centre, Mumbai, Maharashtra
India
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/jpgm.jpgm_518_23
How to cite this article:No wonder tuberculosis is extremely notorious for confusing even the best of clinical minds even though we are now equipped with an entire armamentarium of laboratory investigations. Rare sites harboring the tubercular bacillus are the pancreas and the esophagus, among others.[1]
Patel et al.[2] in this issue of the journal present a rare “double whammy” with tubercular infection of the scrotum and the pancreas. Interestingly, neither is the patient immunodeficient and nor does he have any major constitutional symptoms of weight loss, fever, or contact with a patient with tuberculosis. The clinical dictum of ability to explain two different symptoms by a single etiology (or etiological agent) may not always be easy to affirm. Scrotal involvement in the disease of pancreas is rare, and the opposite is equally true. Chen et al.[3] described left scrotal swelling caused by severe acute pancreatitis in a 38-year-old Chinese man. They described the extension of pancreatic collection into the groin, involving the inguinal canal and scrotum as a rare complication of acute pancreatitis. Similarly, Sutalo et al.[4] described scrotal abscess as the first symptom of fatal acute necrotizing pancreatitis in a 45-year-old man.
This prompts us to ask the question of whether a preceding unrecognized episode of pancreatitis triggered off the cascade of events in this index patient. However, history does not support this hypothesis, which leads us to the second question of how the patient acquired scrotal tuberculosis and prompts to explore the route of acquisition and path of lympho-venous drainage of genital tuberculosis. Genital tuberculosis, in this case epididymitis and scrotal sinus formation, is usually a consequence of spread from the kidneys, urinary bladder, and prostate and subsequently into the genital tract. Rarely, it may follow the path of transurethral reflux, especially in a sexually active man. Tests for the human immunodeficiency virus enzyme-linked immunosorbent assay (HIV ELISA) and sexually transmitted diseases such as syphilis turned out to be negative. It is further possible that a disseminated tuberculous infection does exist in this patient, of which the overt manifestations are seen externally in the form of scrotal sinuses. Serendipitously, the patient developed upper abdominal pain during his hospital stay prompting better cross-sectional imaging, which opened up a pandora's box! Antitubercular therapy fortunately led to the resolution of both covert and overt manifestations of tuberculosis in the index patient, who happens to be a young man.
It is worthwhile again to note that young males with scrotal swelling with abdominal lymph nodes and peripancreatic inflammatory masses may arouse suspicion of germ cell tumors with metastatic spread to intraabdominal retroperitoneal lymph nodes. The primary drainage for left-sided tumors includes the para-aortic and preaortic lymph nodes, followed by the inter-aortocaval nodes, while the lesions on the right side drain into the inter-aortocaval nodal group, below the renal hilar vessels. Right-sided testicular tumors may drain to the left-sided nodal groups but not vice versa.[5] Wehrschütz described metastatic right-sided seminoma in a 57-year-old man mimicking a pancreatic head malignancy.[6] However, the index patient had extra-testicular involvement, which narrowed down and helped streamline the thought process.
Dissemination of tubercular bacillus via lymphatics is common, and whether the genital disease was primary and further spread occurred via the lymphatics to reach the para-aortic nodes and subsequent pancreatic or peripancreatic involvement may be a distant hypothesis.[7]
The authors have been diligent to estimate immunoglobulin G4 (IgG4) levels, which would be a close differential, especially in peripancreatic masses with encasement of adjacent vascular structures. IgG4-related disease should be suspected in the setting of pancreatic masses and obstructive jaundice, extensive lymphadenopathy, or retroperitoneal masses. Identifying this entity by both serum IgG4 levels, the ratio of IgG4: total IgG in blood and tissue immunohistochemistry where a dense polyclonal lymphoplasmacytic infiltrate enriched with IgG4-positive plasma cells would aid the diagnosis and possibly avoid unnecessary surgical procedures.[8]
Endoscopic ultrasound has been a boon in recent times, especially with tissue acquisition from the peripancreatic and para-aortic regions, which helped clinch the diagnosis in this case. Moreover, with a favorable response to antitubercular therapy, there is little room for thought for alternative diagnoses. It would have been interesting to know about the urinary acid-fast bacillus report, albeit with compromised sensitivity for this investigation. Though infection with tuberculosis is a stigma, this organism still, despite its hide-and-seek behavior creating a mirage of sorts, when recognized correctly, has a potential cure with therapy that has a defined duration.
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