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Testicular cancer presenting as disseminated tuberculosis: A case report

ABSTRACT: Introduction and Importance: Tuberculosis is one of the leading infectious causes of mortality worldwide. In the United States, foreign-born persons account for 70% of tuberculosis (TB) diagnoses. Comparatively, testicular cancer is much less common. However, metastatic disease may present similarly. Diagnosis is supported by elevated tumor markers and radical orchiectomy with specimen biopsy confirms the diagnosis and tumor type. Following resection, adjuvant treatment for metastatic disease includes chemotherapy. Case Presentation: This case describes a 22-year-old male immigrant with shortness of breath as the presenting symptom. Chest imaging showed a cavitary lung lesion encroaching the bronchus and left atrium. The patient was placed on airborne precautions and a complex hospital course ensued which resulted in the diagnosis of metastatic nonseminomatous germ cell tumor. The patient's 8 cm testicular tumor was treated with radical orchiectomy followed by chemotherapy. His condition deteriorated quickly, and he passed away in the hospital. Clinical Discussion: Metastatic testicular cancer is relatively rare compared to tuberculosis, especially in the immigrant population. Differentiating extrapulmonary TB from metastatic disease can pose a diagnostic challenge due to similar presentations. Complete physical exam including the genitalia is paramount in discerning a diagnosis of testicular cancer. Conclusion: Incidence of metastatic testicular cancer is much less common than extrapulmonary tuberculosis but must always be included on the differential for a young male. Highlights • Though relatively rare, testicular cancer is the most common malignancy among men 20–40 years old in the United States.• In any young man with a persistent cough, metastatic testicular cancer must be evaluated and excluded.• Complete physical exam, including genitalia, is vital following discovery of a lung lesion, especially in a young male.• Delay in diagnosis of testicular cancer may delay treatment resulting in worse patient outcomes.

SUBMITTER: Najdawi F

PROVIDER: S-EPMC8599095 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:IntroductionHuman herpes virus 8 (HHV-8) is mainly responsible for the development of Kaposi's sarcoma and multicentric Castleman's disease in immunocompromised patients with untreated human immunodeficiency virus. Positive viral loads have been described in cases of Kaposi's sarcoma and multicentric Castleman's disease, with higher values found in the latter. We describe the case of a patient with HIV in whom a high level of HHV-8 replication was detected and who contracted an opportunistic disease other than multicentric Castleman's disease or Kaposi's sarcoma.Case presentationA 25-year-old man of West African origin with HIV complained of asthenia, weight loss, fever, and abdominal pain. Physical examination revealed that the patient had adenopathies and hepatosplenomegaly, but no skin or mucosal lesions were seen. Our first presumptive diagnosis was disseminated tuberculosis. However, since the cultures (sputum, bronchoalveolar lavage, blood, urine and lymph node biopsies) for mycobacteria were negative, the diagnosis was expanded to include multicentric Castleman's disease which was supported by high HHV-8 viral loads in the patient's blood: 196,000 copies/ml in whole blood, 39,400 copies/ml in plasma and 260 copies/10E5 in peripheral blood mononuclear cells. However, the histology and positive polymerase chain reaction assay for Mycobacterium tuberculosis complex of a second lymph node biopsy enabled us to conclude that the patient had disseminated tuberculosis and we started the patient on antituberculosis treatment. We analyzed the HHV-8 deoxyribonucleic acid in two other plasma samples (one from six months earlier and the other was 10 days after the positive test) and both yielded negative results. A search for latent and lytic HHV-8 antibodies confirmed that the patient was seropositive for HHV-8 before this episode.ConclusionWe describe the case of a patient with HIV who tested positive for asymptomatic HHV-8 replication during an opportunistic disease suggestive of multicentric Castleman's disease. The initial analysis was nullified by the diagnosis of a disease that was unrelated to HHV-8. This case report underlines the need to clarify the full clinical meaning and implication of a positive HHV-8 viral load in patients with AIDS. The diagnosis of multicentric Castleman's disease needs to be studied further to determine its sensitivity and specificity. Finally, when faced with the dilemma of urgently starting chemotherapy on a patient whose condition is deteriorating and whose clinical presentation suggests multicentric Castleman's disease, high HHV-8 viral loads should be interpreted with caution and histological analysis of lymph nodes or liver biopsies should be obtained first.

Project description:BackgroundTuberculosis (TB) is a leading cause of morbidity and mortality in underdeveloped and developing countries. Disseminated TB may induce uncommon and potentially fatal secondary hemophagocytic lymphohistiocytosis (HLH). Timely treatment with anti-tuberculosis therapy (ATT) and downmodulation of the immune response is critical. However, corticosteroid treatment for TB-associated HLH remains controversial. Herein, we report a successful case of disseminated TB-associated HLH in a pregnant woman with Evans syndrome accompanied by a literature review.Case presentationA 26-year-old pregnant woman with Evans syndrome was transferred to the Third Affiliated Hospital of Sun Yat-Sen University because of severe pneumonia. She presented with cough, fever, and aggravated dyspnea. Nested polymerase chain reaction for Mycobacterium tuberculosis (M. tuberculosis) complex in sputum was positive. Sputum smear sample for acid-fast bacilli was also positive. Metagenome next-generation sequencing (mNGS) of the bronchoalveolar lavage fluid identified 926 DNA sequence reads and 195 RNA sequence reads corresponding to M. tuberculosis complex, respectively. mNGS of blood identified 48 DNA sequence reads corresponding to M. tuberculosis. There was no sequence read corresponding to other potential pathogens. She was initially administered standard ATT together with a low dose of methylprednisolone (40 mg/day). However, her condition deteriorated rapidly with high fever, acute respiratory distress syndrome, pancytopenia, and hyperferritinemia. Bone marrow smears showed hemophagocytosis. And caseating tuberculous granulomas were found in the placenta. A diagnosis of disseminated TB-associated HLH was made. Along with the continuation of four drug ATT regimen, therapy with a higher dose of methylprednisolone (160 mg/day) combined with immunoglobulin and plasma exchange was managed. The patient's condition improved, and she was discharged on day 19. Her condition was good at follow-up with the continuation of the ATT.ConclusionsClinicians encountering patients with suspected TB accompanied by unexplainable inflammation not responding to ATT should consider complications with HLH. Timely administration of ATT combined with corticosteroids may result in a favorable outcome.

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Testicular cancer presenting as disseminated tuberculosis: A case report

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