Case Report: Tuberculosis in hydrocele of the spermatic cord in an older adult

Introduction

Congenital hydrocele, hernia and hydrocele of cord are generally seen in infants and young adults, but it is a rare finding in older adults. A lot of people do not come to clinics or take consultations as the swellings are symptomless and the disease does not affect them in their day-to-day activities. Hydrocele of cord is the fusion of patent processus vaginalis on both ends with the presence of fluid inside. The fluid present is usually sterile as there is no breach in continuity of the peritoneum and hence it does not get infected.¹ The fluid inside the sac generally remains sterile and very rarely surgeons come across infected hydrocele. Long-term use of antibiotics can convert this fluid into sterile pus known as antibioma.²

The differential diagnosis of such swellings can be done using various modalities of investigations. Literature suggests that the best investigations are ultrasonography for differential diagnosis, color doppler to rule out arteriovenous malformation, computed tomography (CT) scan and magnetic resonance imaging (MRI) to rule out obstructed hernia, abdominal communication and pathologies leading to abscess.³

These investigations when done in tandem or subsequently, can help in finalizing the treatment modality, based on the findings. In specific cases of long-standing abscesses, cartridge-based nucleic acid amplification test (CBNAAT) is used as the final diagnostic tool.⁴

Hydrocele of cord is symptomless until and unless there is any trauma or infection. In the case of older men, we also have to rule out obstructed or Richter hernia. For this purpose, ultrasonography and CT scan can be highly useful.³

Case report

A72 year old male patient, farmer by occupation, resident of rural area of Wardha District, Maharashtra, Central India, presented to the Surgery Outpatient Department of Acharya Vinoba Bhave Rural Hospital at Wardha, with a mild painful swelling in the left inguinal region that had been present for one year and chronic infection of hydrocele of cord. The swelling in the left inguinal region was present since birth, but the patient did not experience any disturbing symptoms until the previous year. In February 2022, the patient experienced sudden pain associated with this swelling and a fever of 102°F. He visited a local physician, and was prescribed tablet pantoprazole 40 mg OD, tablet diclofenac sodium 50 mg BD and tablet amoxicillin + clavulanic acid 500 mg + 125 mg for five days, and was given a referral to a higher center for diagnosis and management. However, as he felt better the next morning, he delayed his visit to the higher center. The pain subsided and according to the history given by patient, recurred just once or twice every two months. The patient continued with the symptomatic management prescribed by his clinician without any repeat consultations. He took over-the-counter medications. Finally in April 2023, the patient came to us with complaints of pain with swelling since the last one year. On examination, the patient had a swelling measuring 7 × 10 cm in the left inguinal region (Figure 1). It was soft cystic, had restricted mobility and was mobile only on pulling the testis downwards, clearly indicating hydrocele of cord. The swelling was not tender and the temperature over the swelling was not raised.

Figure 1. Swelling in inguinal region.

The transillumination test on the swelling was absent, indicating that the fluid present in the swelling is turbid and light cannot pass through it. The scrotum was normal and no inguinal lymph nodes were palpable on either sides of the inguinal region. Patient’s vitals were normal and all the laboratory investigations came to be within the normal limits. Ultrasonography report showed infected cystic collection in the spermatic cord. Abdominal ultrasound was normal. We decided to explore it, for which the fitness for the surgery was obtained from the Anesthesia Department. On exploration, the sac was adhered to the spermatic cord. While exploring the sac, we found that the cyst was adhered to the spermatic cord (Figure 2), it ruptured during handling (Figure 3). We excised the remnants of the sac. The remnants of the sac were excised, pus was sent for culture and sensitivity analysis while the cyst wall was sent for histopathology reporting. The wound was kept open with the intention of secondary healing. After a few days when it became clean and covered with red granulation tissue, we closed the cavity with polyglactin 2-0 and Nylon 3-0 (Figure 3). Pre-operative and post-operative antibiotics were administered. The report for culture sensitivity came to be sterile and the histopathological report showed chronic granulomatous infection.

Figure 2. Cyst identified on surgical exploration.

Figure 3. Ruptured sac.

Considering the chronicity of the swelling and the presence of abscesses we decided to rule out tuberculosis, hence CBNAAT was our choice. CBNAAT reporting confirmed that the swelling and abscess was tubercular in origin. As the reports confirmed our diagnosis of antibioma and tubercular cavity, the patient was started on with antitubercular management. The sutures were removed on the 10^th and 11^th post-operative days and the discharge of the patient was without any immediate surgical complications. As documented, tuberculous cavities, ulcers and wounds do not heal without any anti-tubercular treatment, but in this case the patient showed good early healing, to our surprise.

The patient was satisfied and comfortable with our management and decided to extend his hospital stay until the stitch removal, although we wanted to discharge him on the fourth post-operative day.

Discussion

Congenital swelling, that is hydrocele of cord presenting in a 72-year-old male patient is rare by itself. While a diagnosed antibioma confirmed to be of tuberculous origin by CBNAAT is an additional unusual finding.

Infected hydrocele of cord may result from the intrabdominal infection through patent processus vaginalis. It may also be a result of lower urinary tract infection, epididymo-orchitis, incarcerated inguinal hernia, appendicitis or any other abdominal infection. In routine cases it cannot be treated by conservative management and surgery is a must in all the cases of hydrocele of cord.⁵ It may remain dormant for years if not treated and only in very few cases it may convert into abscesses. As we are in a developing country, the socioeconomically poor patients in rural areas may never attend the hospital until or unless they suffer from major discomfort or are scared of malignancy or death.⁶ This is exactly what happened in this case as the patient was lingering on the disease but when it did not subside even after conservative treatment for about a year, that is when he decided to come to the surgery outpatient department. Clearly indicating the lack of health seeking behavior in low and middle-income countries. We could not find any primary cause of infection leading to this abscess.

The team looked at the condition from different angles and narrowed down on tuberculosis considering the presentation and chronicity. Taking a decision to explore the antibioma and suspecting an infection of tubercular origin helped us diagnose and manage the case appropriately.

The complications of inguinal hernia area such as incarcerated hernia, abscess, malignant lymph nodes and cellulitis should be attended on priority basis as some times they may be underdiagnosed, some cases may need urgent consideration otherwise they may prove fatal.⁷

As mentioned, hydrocele of cord is detected in early life and patients usually get operated at an early age. Very rarely would you come across an older patient presenting with this condition. As the swelling was present since birth i.e., most probably congenital in origin, it must have caused discomfort to the patient, but peculiarly the patient went through adulthood without any seemingly obvious discomfort that would have initiated seeking any medical assistance.

The investigations needed for the swelling in this region include CT scan and MRI of the abdomen to rule out hernia, especially an obstructed one. Second line of investigations must be ultrasonography to differentiate between a cystic swelling or solid swelling. If it turns out to be solid; fine needle aspiration cytology (FNAC) or excision biopsy is needed. If it is cystic, either aspiration or excision should be done. A CT scan and MRI are essential for ruling out abdominal pathologies too, which may lead to infected hydrocele of cord.²

For the control of infection, systemic antibiotics can be given along with analgesics, anti-inflammatories along with other symptomatic management.⁸ In pyogenic abscess, the treatment of choice is incision and drainage, but in cases of tubercular abscess an anti-gravity aspiration of the abscess followed by antitubercular management will suffice.⁹ Any chronic abscess present for a long duration should raise suspicions of tuberculosis. CBNAAT examination of fluid is a test that gives a report within two hours and is available at many centers, it is a useful test to diagnose extrapulmonary tuberculosis. Tuberculoma and antibioma of spermatic cord is a rare presentation that we wanted to highlight, as clinicians should also keep it as a differential diagnosis in such types of cases. Furthermore, it is an inspiration for a surgeon to explore the unresolved mysteries in human bodies.

Conclusions

Long standing abscess are mostly tuberculous. In a case of inguinal or inguinoscrotal swelling it is necessary to diagnose it properly. We must look into whether it needs urgent attention or can be managed conservatively as a routine procedure. Every aspect must be scrutinized with necessary investigations and appropriate decisions should be taken and followed by definitive management so that nothing is neglected. Medical science is vast and knowledge must be shared amongst the medical professionals to build their opinions and for the best possible management. The patient was notified to the District Tuberculosis Centre and was started on anti-tuberculosis drugs under the National Tuberculosis Elimination Programme.

Consent

Written informed consent for publication of their clinical details and clinical images was obtained from the patient.