SESSION TITLE: Infectious Diseases Cases
SESSION TYPE: Case Reports
PRESENTED ON: Saturday, March 22, 2014 at 04:15 PM - 05:15 PM
INTRODUCTION: Fournier's Gangrene is a life-threatening necrotizing infection of the perineum which affects immunocompromised patients, including those with diabetes and alcoholism. It is usually polymicrobial in nature, but occasionally results from atypical organisms. We report a rare case of tuberculous Fournier's Gangrene from a presumed prostatic source.
CASE PRESENTATION: A 68 year-old homeless male presented with fevers, severe groin pain, and obstructive nephropathy. Urine cultures grew out Enterococcus, but the patient did not improve on antibiotics. Upon closer inspection, he had severe cellulitis of both thighs and external genitalia. Fournier's Gangrene was suspected, and the patient was taken to emergent surgery. Tissue cultures were positive for Streptococcus, Staphylococcus, Proteus, and Escherichia. However, because of continued fevers, recurrent urinary infections, and extension of his leg abscesses, the patient underwent further debridement and cultures retuned positive only for AFB. The suspicion of tuberculosis, based on CT findings of bi-apical pulmonary and prostatic calcifications, was confirmed, and the patient was started on anti-mycobacterial therapy but died of overwhelming sepsis.
DISCUSSION: Of all extrapulmonary tuberculosis cases, only 6.5% involve the genitourinary tract, with the kidney and bladder being the most common sites of infection. Prostate involvement is even rarer, yet it accounts for 77% of all deaths. Diagnosis of prostatic tuberculosis is often found only on autopsy, or incidentally during transurethral prostatectomy. Hematogenous seeding of any urogenital organ commonly requires many years of pulmonary tuberculosis and is more likely if immunocomprimised. Therefore, a diagnosis of prostate tuberculosis should prompt workup for pulmonary and kidney/bladder involvement, as well as screening for HIV. Reasons for missed detection include nonspecific symptoms of frequency and nocturia, confounding bacterial co-infections with pyleonephritis or epididimitis, and lack of physician awareness. Because the prostate is at the external sphincter, the classic clue of sterile pyuria is only helpful when collected properly using the "4 Glass Test". Prostate massage yields secretions which can be sent for AFB culture; however, only 36% of such cases are positive and thus PCR evaluation may be necessary. Utilitizing a "provocation test" by placing a PPD prior to secretion collection may increase the diagnostic yield by 16%. Transrectal ultrasound can also be helpful in detection if irregular hyperechoic lesions are found at the periphery of the gland.
CONCLUSIONS: In our patient, the tuberculous abscesses were presumed to be local prostatic seeding given the occult nature of this disease and lack of active pulmonary tuberculosis or evidence of wide-spread dissemination.
Reference #1: Clin Infect Dis(2009) 49: 1350-7
Reference #2: World J Urol(2012) 30:15-21
Reference #3: Int J Urol(2008) 15: 827-832
DISCLOSURE: The following authors have nothing to disclose: Jason Schnack, Aarti Mittal, Ching-Fei Chang
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