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Case Report

Case Report: Prostatitis tuberculosis mimicking prostate cancer

[version 1; peer review: 2 approved with reservations]
PUBLISHED 18 Nov 2020
Author details Author details
OPEN PEER REVIEW
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Abstract

A 56-year-old male who presented with recurrent gross hematuria and moderate lower urinary tract symptoms. After taking the patient’s medical history and performing a physical exam, suspicion of prostate cancer arose with prostate enlargement during rectal examination without tenderness and palpable nodes. Ultrasound showed estimated prostate volume of 95 gr and prostate specific antigen of 5.5. Transurethral resection of the prostate was performed and prostate tissue was checked by a pathologist, with histopathological examination showing active tuberculosis lesions. An interferon gamma release assay test was performed, which showed a positive result. The patient was diagnosed with prostatitis tuberculosis and treated with standard nine-month regimen for extra-pulmonary tuberculosis. Prostate enlargement due to tuberculosis is rare and its presence may mimic prostate cancer presentation; however, due to its rarity, careful examination is needed in order to provide optimal management.

Keywords

Prostatitis, Tuberculosis, Prostate Cancer, Genitourinary Tuberculosis, Prostate Enlargement

Introduction

Tuberculosis (TB) is a chronic condition that is still endemic in Indonesia, with more than 800,000 new cases in 2018. Most cases are primary lung TB (88%); however, the genitourinary tract is one of the most common sites of hematogenous spread of extra-pulmonary TB. Genitourinary TB (GUTB), first introduced in 1937 by Wildbolz, is the second most common form of extra-pulmonary TB in endemic countries1. While male genital TB incidence are relatively low, in men, TB may affect the epididymis and the prostate (most common), followed by the seminal vesicles and the testicles13.

We present the case of a 56-year-old male who presented with recurrent gross hematuria and moderate lower urinary tract symptoms.

Case presentation

A 56-years-old male presented to the urology clinic with gross hematuria, which had been experienced for the past three months. Hematuria was intermittent and recurrent, with no history of urinary retention or previous trauma. The patient was also experiencing moderate lower urinary tract symptoms (LUTS) with daytime urinary frequency, poor urinary stream, nocturia up to three times a night, straining on bladder emptying and a sensation of incomplete emptying. His International Prostate Symptom Score was 18/35, indicating moderate symptoms, with 4/6 for the quality-of-life component, indicating mostly dissatisfied due to the symptoms. Physical examination was unremarkable, with no other comorbidities and no history of previous surgery. Digital rectal examination was performed, revealing a normal anal tone, normal perianal sensation, but an enlargement of the prostate with a firm consistency and smooth surface. Tenderness and palpable nodes were not found.

Workup was performed, revealing that blood markers were unremarkable with normal renal function, and a prostate specific antigen (PSA) value of 5.5 ng/dL (normal range, <4 ng/dL). Ultrasound and CT scan revealed prostate enlargement (Figure 1), with estimated volume of 95 gr. Cystoscopy and transurethral resection of the prostate (TUR-P) were performed for diagnosis as well as therapy to reduce prostate volume. During cystoscopy, the bladder was found to be unremarkable; the bladder wall was normal, with no mass or stone found. The prostate was found enlarged with protrusion to the bladder cavity, and a kissing lobe were found. Resection of the prostate was performed systematically and resected tissue was sent to pathology.

b2c0c835-ac9e-4c6d-a61d-352d8f6971c2_figure1.gif

Figure 1. Multi slice computed tomography scan of lower abdomen showing prostate tissue enlargement.

Pathology result showed a typical tuberculosis specimen with tubercles, consisting of epithelioid cells, central necrosis mass accompanied by chronic inflammatory lymphocyte cells, and presence of Langhans type of multinucleated giant cells (Figure 2). Interferon gamma release assay (IGRA) test was then performed to confirm TB diagnosis, which was positive.

b2c0c835-ac9e-4c6d-a61d-352d8f6971c2_figure2.gif

Figure 2. Prostate histopathology taken from TURP procedure.

The patient was given standard regimen treatment (combination of isoniazid, rifampicin, ethambutol and pyrazinamide for 2 months and isoniazid and rifampicin for the next 7 months) for TB for nine months, with evaluation of symptoms every three months. Evaluation and follow up consisted of history and physical examination, urinalysis and urine cytology and ultrasound of bladder and prostate. After 9 months of oral therapy, an additional CT scan was performed resulting normal prostate image.

Discussion

TB is a long-term health issue in Indonesia. Current challenges with TB are increased incidence due to drug-resistant cases and HIV spread1. One of the most common sites of extra-pulmonary TB is the genitourinary tract, as it is the primary target of hematogenous infection. The kidney is the most common site of infection in the genitourinary tract. Prostatitis TB is a rare and uncommon presentation of extra-pulmonary tuberculosis. As a type of GUTB, diagnosis of this disease are challenging, as signs and symptoms, such as LUTS and hematuria, may mimic other disorders, such as urinary tract infection, benign prostate hyperplasia, and prostate cancer. Most of the time, diagnosis of prostate TB are incidental, for example made by the pathologist while performing examination of prostate tissue specimen taken from biopsy or prostate resection1,2,4. TB in the male genitalia is commonly found in the prostate or epididymal. Some of the most common symptoms are frequent urination, nocturia, dysuria, hematuria, urgency, and hematospermia. On physical examination indurations and nodules on the prostate can be found, which makes it difficult to distinguish from another malignancy; indeed it might be concurrent with other malignancies2,3. However, TB in the prostate is often asymptomatic, and has been shown to be found in about 10–14% of autopsy cases2.

Investigation for suspected prostate TB can be done by examining leukocytes on a three glass urine test, prostate massage secretions, ultrasound examination, and anatomical and cultural pathology examination. The gold standard is biopsy, and confirmation can be done by PCR test3. In our case, the patient had moderate LUTS symptoms and hematuria for the last three months. After examination, an enlargement of the prostate with high PSA value was found. After confirming the enlargement with ultrasound and CT scan, a TUR-P for biopsy was done which returned the result of TB. The positive IGRA test was used for confirmation. The IGRA test cannot be used alone because it will most likely always be positive in an endemic environment for TB, such as Indonesia. An alternative for TB confirmation is PCR.

Management of prostate TB is the same as other extra-pulmonary TB; administration of isoniazid, rifampicin, pyrazinamide and ethambutol or streptomycin every day for two or three months, followed by administration of isoniazid and rifampicin every day for six to seven months (for a total of nine months treatment). In our case, we used a nine month TB drug treatment, with follow-up of the symptoms every three months. Extra-pulmonary tuberculosis including genitourinary TB has a low mortality rate3.

Consent

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

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Warli SM, Kadar DD and Warli MH. Case Report: Prostatitis tuberculosis mimicking prostate cancer [version 1; peer review: 2 approved with reservations]. F1000Research 2020, 9:1345 (https://doi.org/10.12688/f1000research.26488.1)
NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.
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Open Peer Review

Current Reviewer Status: ?
Key to Reviewer Statuses VIEW
ApprovedThe paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approvedFundamental flaws in the paper seriously undermine the findings and conclusions
Version 1
VERSION 1
PUBLISHED 18 Nov 2020
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7
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Reviewer Report 26 Apr 2021
Zhuo Tony Su, Johns Hopkins University, Baltimore, Maryland, USA 
Approved with Reservations
VIEWS 7
The report is well and concisely written and the topic is of interest. 

Limited description is available of the patient's past medical, surgical and social history and occupational/environmental exposure. 

In the abstract, the authors ... Continue reading
CITE
CITE
HOW TO CITE THIS REPORT
Su ZT. Reviewer Report For: Case Report: Prostatitis tuberculosis mimicking prostate cancer [version 1; peer review: 2 approved with reservations]. F1000Research 2020, 9:1345 (https://doi.org/10.5256/f1000research.29245.r82989)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
Views
15
Cite
Reviewer Report 18 Feb 2021
Dahril Dahril, Department of Urology, Faculty of Medicine, Dr. Zainoel Abidin General Hospital, Universitas Syiah Kuala, Banda Aceh, Indonesia 
Approved with Reservations
VIEWS 15
  1.  Pulmonary tuberculosis is the most common and most contagious form of tuberculosis, so if extrapulmonary TB is found, a comprehensive evaluation of the patient suspected of having TB should be done, including clinical history, physical exploration, chest
... Continue reading
CITE
CITE
HOW TO CITE THIS REPORT
Dahril D. Reviewer Report For: Case Report: Prostatitis tuberculosis mimicking prostate cancer [version 1; peer review: 2 approved with reservations]. F1000Research 2020, 9:1345 (https://doi.org/10.5256/f1000research.29245.r78265)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.

Comments on this article Comments (0)

Version 1
VERSION 1 PUBLISHED 18 Nov 2020
Comment
Alongside their report, reviewers assign a status to the article:
Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions
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