Nodulo-ulcerative Tuberculosis of the Glans Penis-A Case Report and a Discussion on Nomenclature of Genital Tuberculosis.

Lupus vulgaris is a chronic paucibacillary form of cutaneous tuberculosis occurring in a person with a moderate to high degree of immunity. It commonly occurs over the buttocks and trunk in India. Involvement of the genitalia is uncommon, and lesions involving the penis, extremely rare with few cases reported worldwide. There also exists a confusion regarding nosology of tuberculosis of the genitalia. A brief discussion and review of literature are being discussed along with the report of a case of genital tuberculosis involving the glans penis.

What was known?

Genital tuberculosis is an uncommon form of cutaneous tuberculosis and also of non-healing genital ulcers. Few cases have been reported worldwide. There also exists confusion regarding the nomenclature for these lesions.

Introduction

Genitourinary tuberculosis (TB) is a common site for extra pulmonary tuberculosis. But tuberculosis of the penis is an extremely rare entity with few cases described in the literature. It is often a diagnosis of exclusion after ruling out other causes of genital ulcers, nodules, malignancy and other clinical conditions.

Case Report

A 55-year-old-male patient, who was a farmer by profession, presented to our Dermatology out-patient Department with complaint of a long-standing, non-healing, painless lesion over his genitalia for last 12 month. Initially there was an erythematous nodule that gave rise to multiple ulcers over the glans penis and around the urethral meatus.

The patient was married with two children. There was no history of any high risk behavior including history of exposure in either the husband or the wife. The wife had no symptoms and her clinical examination was within normal limits. There was no history of any similar lesion in the past, bleeding from the lesions or any urethral discharge. He had no history of any evening rise of temperature or loss of weight in the recent past. He had been vaccinated with BCG vaccine at birth. He had tried different treatment modalities without any response. He was in good health overall, but concerned about the genital lesion.

On examination of the penis, the prepuce was mobile and retractable. There were multiple shallow ulcers, some of them confluent, with undermined edges and yellow granulomatous indurated base over the glans penis. They were of variable sizes and measured from 3mm to 5mm and from 4mm to 6 mm in size [Figure 1]. There were no signs of tenderness and inguinal lymphadenopathy. Examination of rest of the genitalia was within normal limits.

Figure 1

Multiple shallow ulcers with undermined edges and indurated base over the glans penis of a 55 year-old-man

Laboratory investigations revealed a raised ESR (40 mm for 1st hour). Serologic tests for HIV and VDRL tests were negative. Dark field examination for Treponema pallidum, Gram stain for Haemophilus ducreyi, smear for Donovan bodies and Tzanck smear for giant cells were all negative. Microscopic examination of urine and culture revealed no abnormality. Acid fast bacilli were not demonstrable in either scraping from the ulcer base, urine or sputum. Ultrasonography of the kidney, ureters and bladder was within normal limits. Mantoux test was strongly positive (22 × 25 mm) [Figure 2]. Chest radiograph was within normal limits. A biopsy from the lesion revealed characteristic findings on histopathological examination. The epidermis was ulcerated with an epithelioid granuloma with central caseation necrosis. Numerous Langhans type of giant cells were seen with lymphoid cell infiltration [Figures 3 and 4].

Figure 2

The same lesion with highly positive Mantoux test

Figure 3

Histopathology showing ulcerated epidermis with epithelioid granuloma with central caseation necrosis (HandE stain, 40×)

Figure 4

Histopathology showing numerous Langhans type of giant cells with lymphoid cell infiltration (HandE stain, 100×)

Based on the above-mentioned findings, the patient was diagnosed with tuberculosis of the glans penis. He was started on anti-tuberculosis therapy (ATT) under Category I as per the Revised National Tuberculosis Control Program (RNTCP). The patient came for regular follow-up and there was complete subsidence of the lesions after 6 months of therapy with ATT [Figure 5].

Figure 5

The same patient with resolution of genital lesions after treatment with ATD for 6 months

Discussion

TB of the genitourinary tract is the most common site for extra pulmonary disease.[1] But TB of the penis is extremely rare. Very few cases have been described worldwide with less than 1% of all genital TB cases reported. The usual sites of involvement described in decreasing order of frequency are epididymis (42%), seminal vesicle (23%), prostrate (21%), testis (15%) and vas deferens (12%).[2] Penile TB can be either primary or secondary to pulmonary or systemic TB.[3] In the penis, the sites of involvement may be the glans, skin or around the coronal sulcus. Usually it presents as a chronic nodulo-ulcerative or papulonodular lesion. Other rare clinical type's maybe scrofulous gumma and phagedenic infection with destruction of the penis.[45] Possible modes of transmission maybe either sexual (from a partner affected with genitourinary TB), by direct inoculation from contaminated hands or clothing, reactivation of bacilli or hypersensitivity to their antigens.[6789]

Our patient was a farmer by profession, his wife was not suffering from genitourinary TB and neither had any history of extra marital coitus.

Genital TB responds very well to ATT and treatment should be instituted promptly. But a single case of drug-resistant penile TB has also been reported in the literature.[10]

There also exists confusion regarding the nomenclature of penile TB. In other parts of the skin, the nomenclature is often based on the clinical picture. A review of literature reveals varying nomenclature of penile TB ranging from primary TB, secondary TB, true TB, penile tuberculide, papulonecrotic tuberculide and ulcerated lupus vulgaris. Ramesh et al. have stated that since demonstration of acid-fast bacilli on histopathology or isolation in culture is seldom positive, it becomes difficult to distinguish tuberculides from other forms of cutaneous tuberculosis (like lupus vulgaris). Hence, lesions localized to the glans penis may be more appropriately referred to as “tuberculosis of glans penis.”[4]

Conclusion

Any chronic non-healing ulcer over the penis should arouse a suspicion of tuberculosis, especially in an endemic country like India. A keen clinical eye will help to diagnose this condition early and treatment with ATT gives good response. Surgical intervention is rarely needed if the rest of the genitourinary system is not involvement. The patients should also be followed up till resolution of the lesions, as resistant TB is also a possibility in some cases.

What is new?

Genital tuberculosis is an important cause of non-healing genital ulcers and the entity needs to be kept in mind. Moreover, keeping in mind the diverse nature of clinical and histopathological presentations, “genital tuberculosis” seems to be a more appropriate terminology.