Tuberculoso orchiepididymitus in insulinodependent Type 2 diabetes Mellitus: Case report

Introduction: There is little information in Peru on the association of tuberculous orchiepididymitis in relation to immunosuppressed patients, being an endemic country of tuberculosis and there is an increase in the prevalence of chronic noncommunicable diseases such as diabetes, producing wrong diagnoses. Clinical Case: We present the case of a 70-year-old man with a history of type 2 diabetes mellitus who was admitted to the outpatient clinic due to dysuria and frequency. On physical examination, a hard, non-painful right testicle, the ultrasound showed signs of epididymal abscess in the scrotal wall of the Right testicle, which is why an infected neoplasm is suspected, and a right orchiectomy is performed, later in the histological study, multinucleated Langhans-type giant cells with granulomatous areas suggestive of tuberculosis are shown, which is why it is proposed that in the presence of urological symptoms in immunosuppressed patients, it is ruled out tuberculosis.

Introduction: Peru has little information about the association of tuberculous orchiepididymitis in relation to immunosuppressed patients, being a country endemic for tuberculosis and having an increased prevalence of chronic non-communicable diseases such as diabetes, leading to misdiagnosis. Clinical Case: We present the case of a 70-year-old man with a history of type 2 diabetes mellitus who was admitted to the outpatient clinic due to dysuria and frequent urination. On physical examination, the right testicle was hard, not painful. The ultrasound showed signs of epididymal abscess in the scrotal wall of the right testis, so an infected neoplasm is suspected, performing a right orchiectomy. Later in the histological study, they show giant multinucleated Langhans-type cells with granulomatous areas suggestive of tuberculosis, so it is suggested that in the presence of urological symptoms in patients immunosuppressed tuberculosis is ruled out.

INTRODUCTION
The global prevalence of diabetes is 8,3%; In Latin America, the prevalence of diabetes is 5%. In Peru, there is insufficient epidemiological data on DM: however, some studies suggest a prevalence of 5 to 7% .
According to the World Health Organization, in 2016, there were an estimated 10,4 million new cases of active tuberculosis (TB) per year, and 1,8 million deaths in 2015 (3) from Mycobacterium tuberculosis .
The association between TB and DM was described in the middle of the 20th century. Evidence supports the hypothesis that DM increases the susceptibility to (5) developing TB due to immunode ciency . However, the emergence of comorbidities such as HIV / AIDS and diabetes mellitus (DM) jeopardize the goal of global TB Through this case, it is proposed that in the presence of urological symptoms in immunosuppressed patients, tuberculosis should be ruled out before any surgical procedure, on the other hand, it is proposed to analyze the relationship that exists between the state of Around 15% of extrapulmonary TB represents genitourinary tuberculosis; since it is the second common manifestation in the countries of Europe. Commonly infected sites are the epididymis, seminal (1) vesicle, prostate, and testes .
Genital TB is rare, and testicular TB is even more infrequent, comprising only 3%. Thus, scrotal infection by Mycobacterium tuberculosis occurs in 7% of patients (1) ; being the most common site of genital TB, the epididymis, followed by the seminal vesicles, the prostate, the testicles, and the vas deferens. As the epididymis is affected rst, orchitis occurs by contiguous extension and re ects a late stage of the disease. Other authors postulate dissemination through the pelvic lymphatic system and venereal (2) transmission , with the most affected middle-aged men.
In Peru, the evidence on the effect of DM and TB is scarce; Only one cohort study in patients at high risk of (7) resistant TB was associated with 11% with DM .

DESCRIPTION OF THE CLINICAL CASE
This is a case of a 70-year-old man from Huancayo-Junín, with insulin-dependent diabetes mellitus type 2, prostatectomy 10 years ago, and intermittent urinary infection without response to antibiotic treatment. The patient is admitted with dysuria and frequency of 1month evolution; He denies contact with tuberculosis, fever, sweating, and weight loss.
Macroscopic study: right testicle plus epididymis 8x4cm, smooth surface; On cut, yellowish brown stroma with a focus of purulent secretion.

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A testicular neoplasm is suspected and added to the ultrasound ndings of an epididymal abscess based on age and physical examination. An infected testicular neoplasm is proposed as a diagnosis, indicating right orchiectomy.
Histopathology: positive acid-fast bacillus (AFB) staining, areas of brosis, and mixed in ammatory in ltrate with the presence of giant multinucleated Langhans-type cells with granulomatous areas that de nes a diagnosis of tuberculous orchiepididymitis and initiates antituberculous treatment with isoniazid, rifampicin, pyrazinamide, and ethambutol (2HRZE + 4HR) for 6 months. The patient evolved favorably. genitourinary tuberculosis was the outcome of our patient; however, the involvement of other organs such as the prostate, seminal vesicle, vas deferens, testicle, penis, and epididymis is also reported as a frequent ( 6 ) complication . Thus, it is pointed out that g e n i to u r i n a r y T B re p re s e n t s 5 % o f c a s e s o f extrapulmonary tuberculosis, the most frequent location being the epididymis, as it was in the case (7) presented .
At the age of 40 years, urogenital tuberculosis is twice more frequent in men than in women, suggesting that the presence of urinary symptoms and sterile pyuria has renal compromise. On the other hand, a pulmonary alteration can be visualized in the imaging study even in 75%. In our case, the patient reported having presented dysuria and intermittent frequency with an evolution (6) time of up to one month, coinciding with the literature ; however, no apparent primary pulmonary focus was found since the chest tomography did not show characteristics of having suffered from this disease.

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Physical examination ndings may include a tender nodule, dilation, and thickening of the epididymis. Testicular involvement can be unilateral or bilateral. Epididymal involvement classically shows up as a heterogeneous hypoechoic mass on ultrasonography.
In the urinalysis, albuminuria or hematuria may also be (7) observed. Others report cases of infertility .
Clinically, it is not usually distinguishable from the testicular tumor, acute infection (bacterial or viral), granulomatous infection (sarcoidosis), or infarction, and can even, in some cases, mimic testicular torsion . Epididymal enlargement and thickening of the scrotum are the key points of infection.
Testicular ultrasound is currently the best technique for the diagnosis of testicular injury. Here, a great thickening and formation of a dense, caseous mass are observed, which can rupture and give rise to tedious stulas. Other sonographic ndings include thickening of the scrotal skin, hydrocele, calci cations, and scrotal abscess. The addition of Doppler ultrasound serves to assess blood ow and helps differentiate testicular (5) infarction, tumor, or in ammation .
In our case, a patient with immunosuppression, diabetes, compatible symptoms, and histology with epithelioid granulomas, caseous necrosis, and Ziehl-Neelsen staining con rmed the diagnosis.
Regarding the presence of DM, data indicate that having HbA1c greater than seven is a risk factor for (9) latent tuberculosis . In addition, there are differences in the pharmacokinetics of drugs for TB and DM and other comorbidities such as hypertension or obesity, which (10) leads to a higher risk of death and relapse .
In endemic countries such as Peru, patients with symptoms such as long-standing dysuria and frequency of urination, scrotal mass, or chronic epididymitis should be evaluated for tuberculosis. This The evidence recommends antituberculous treatment with the usual regimen of isoniazid, rifampin, pyrazinamide, and ethambutol (2HRZE + 4HR) for 6 months, through which cure rates of 95% are obtained.
However, surgical intervention may be necessary, especially in severe cases, such as no clinical response to treatment, increased testicular size, and edema or (11) abscess formation .
One of the challenges that occur in patients with DM-TB is therapeutic management since it has been shown that the levels of anti-TB drugs in plasma are below (12) therapeutic values . This, added to hyperglycemia, makes management difficult.
There are still no randomized studies that evaluate an adequate treatment for TB-DM, and there is not enough evidence to evaluate the effect of insulin or (13) metformin , with the use of the insulin being (14) recommended in Peru .
Authorship contributions: All the authors have participated in the article's conception, the data collection, its writing and approval of the nal version.
Funding sources: Self-nanced Con icts of Interest: All authors declare that they have no con icts of interest.