Granulomatous epididymo-orchitis: diagnosis by fine needle aspiration

Introduction

Granulomatous epididymo-orchitis is a term that encompasses a group of pathologies with different aetiology. ¹ Tuberculosis (TB) is the most common cause in low- and middle-income countries.^2,3 Involvement of the epididymis is fairly common while the testis is rarely involved, but the latter is often mistaken as a malignancy. ⁴ Fine needle aspiration (FNA) is a minimally invasive diagnostic modality and the aim of our study was to evaluate the cytomorphology of granulomatous epididymo-orchitis. The findings were correlated with the nature of material aspirated and the status of acid fast bacilli (AFB) on Ziehl Neelsen (ZN) staining.

Patients and methods

Ours was a retrospective study of 40 patients diagnosed with granulomatous or tuberculous epididymo-orchitis on FNA between January 2002 and December 2015. FNA was performed as an outpatient procedure, whose details were explained to, and informed consent obtained from, the patient beforehand. In a relaxed supine position, the patient’s scrotum was prepared with 5% betadine solution, and the suspect swelling or nodule was fixed between index finger and thumb before aspirating, using a 23G needle attached to a 10-mL disposable syringe mounted on a syringe holder, with the other hand. There were no significant complications noted. Both air-dried and wet-fixed smears were made and stained with May Grünwald giemsa and haematoxylin and eosin (H&E), respectively. ZN staining for AFB was also performed in all the cases. Periodic acid Schiff staining (PAS) was carried in AFB-negative cases to rule out a fungal aetiology. FNA findings were correlated with the histopathology wherever available. Following the cytological diagnosis of granulomatous or tubercular epididymo-orchitis, patients underwent clinical workup including erythrocyte sedimentation rate (ESR), chest radiography, sputum cytology, Mantoux testing and abdominal, pelvic and scrotal ultrasonography.

Results

Patients were in the age range of 16–70 years. Data are shown in Table 1. Correlation between material aspirated from and cytologic features of smears in testicular or epididymal swellings is shown in Table 2. Epithelioid cell granulomas (Figure 1), caseous necrosis (Figure 2), mixed inflammatory cells, Langhans’ giant cells, fibroblasts, granulation tissue and epididymal cells were seen in varying proportions. Careful search for AFB on ZN-stained smears showed positivity (Figure 2) in 15 patients (37.5%). PAS smears searching for fungal elements in AFB negative patients were all negative.

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Table 1.

Symptoms and signs of patients with presumptive clinical diagnosis.

Symptoms and signs	Presumptive clinical diagnosis	Patients (n (%))
Painless epididymal and testicular lump	Neoplasm	16 (40)
Epididymal nodule along with fever	Tubercular epididymo-orchitis	9 (22.5)
Tender epididymal nodule	Chronic epididymo-orchitis	12 (30)
Epididymal and testicular enlargement with inguinal lymphadenopathy	Tubercular epididymo-orchitis	2 (5)
Epididymal and testicular nodules with infertility	Chronic epididymo-orchitis	1 (2.5)

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Table 2.

Correlation between material aspirated and cytologic features of smears in testicular/epididymal swellings (n = 40).

Material aspirated; patients (n (%))	Cytological features			AFB status; patients (n (%))	Aspiration diagnosis
	Caseation	Epithelioid cell granuloma with caseation	Epithelioid cell granuloma
Purulent; 16 (40)	4	12	0	Positive; 12 (75)	Tubercular epididymo-orchitis
				Negative; 4 (25)	Granulomatous inflammation suggestive of TB
Cheesy/necrotic; 3 (7.5)	0	3	0	Positive; 3 (100)	Tubercular epididymo-orchitis
Mixed with blood; 12 (30)	0	2	10	Negative; 2 (16.7)	Granulomatous inflammation suggestive of TB
				Negative; 10 (83.3)	Granulomatous inflammation
Drop of fluid; 9 (22.5)	0	0	9	Negative; 9 (100)	Granulomatous inflammation

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Figure 1.

FNA smear showing epithelioid cell granuloma (May Grünwald giemsa ×400).

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Figure 2.

Aspirate showing large areas of caseous necrosis in tubercular epididymo-orchitis (May Grünwald giemsa ×100). Inset shows acid fast bacilli (ZN ×1000).

Findings of healed pulmonary TB were observed on chest radiography in four patients. The Mantoux test was positive in 26 while ESR was raised in 19. Of 16 cases with a clinical diagnosis of testicular neoplasm, biopsy was done in four and an orchidectomy specimen was reviewed in one instance. The histopathological diagnosis in all these cases was granulomatous inflammation suggestive of TB. Polymerase chain reaction (PCR) testing was not done owing to cost constraints. All the patients were started on anti-tubercular therapy (ATT) comprising rifampicin, isoniazid (INH), ethambutol and pyrazinamide in standard doses for two months with continuation of rifampicin and INH for another four months. After initiation of ATT, local and constitutional symptomatic relief with a gradual decrease in scrotal swelling was seen in all but one patient in whom orchidectomy was performed.

Discussion

A painless, solid testicular or scrotal lump is generally considered malignant with only rare exceptions, ² which may be grouped under infective and non-infective causes of granulomatous epididymo-orchitis.^5–7 Its varied aetiology includes TB, brucellosis, syphilis, lepromatous leprosy, fungal infection, sarcoidosis, malakoplakia and xanthogranulomatous, and idiopathic changes. ¹ TB is by far the most common. ² The most common clinical presentation was that of a firm to hard scrotal nodule.^8–10 In 60% of cases, a presumptive diagnosis of TB was made on the basis of other associated symptoms or signs but in 40% a testicular neoplasm was suspected. One single patient presented with infertility, an uncommon complication of male genital TB. ⁴

Ultrasonographic findings of a testicular tumour and granulomatous epididymo-orchitis are very similar, as both may show an enlarged heterogeneous testis with deformation of testicular contour. ¹¹ The presence of epithelioid cell granulomas, Langhans’ giant cells, caseous necrosis and positivity for AFB are diagnostic features confirming tubercular epididymo-orchitis. We found AFB in patients with purulent or cheesy aspirate, while those with blood mixed or entirely fluid aspirates were AFB-negative. AFB culture remains the gold standard for diagnosing TB but takes six to eight weeks for isolation, by which time a patient is often lost to follow-up. PCR may facilitate the diagnosis. ¹² However, the setup is often still wanting owing to cost constraints.

Where TB is endemic and no definitive diagnosis has been made, a final diagnosis of granulomatous inflammation suggestive of TB may still be entertained. ¹³ In our study, 19 cases (47.5%) were AFB-negative and lacked caseation. Evaluating PAS smears may be helpful in this situation. An absence of sperm fragments and macrophages containing engulfed spermatozoids is helpful in excluding spermatic granuloma. ¹⁴ Careful search for tumour cells should also be made in each case to exclude a testicular tumour. Inflammation and necrosis may be seen in embryonal carcinoma and seminoma. ¹⁵ Furthermore, the presence of plentiful lymphocytes in association with epithelioid cells or granulomas mandates the exclusion of a seminoma.

TB is a great mimicker of neoplasm. Thus, a histopathological diagnosis of tubercular epididymo-orchitis in an orchidectomy specimen is no surprise. ¹⁶ We found one such case in our study, but almost always represents an unwarranted and unjustifiable intervention. The potential risk after FNA of tumour seeding in the needle track is unproven.^15,17,18 To the contrary, FNA may help by suggesting the correct surgical approach depending on tumour type. ¹⁹ FNA offers several advantages over a testicular biopsy besides being cost-effective. ¹⁸ A biopsy specimen may anyway not be representative and artefacts may make correct interpretation problematic. A quick, reliable diagnosis with FNA in conjunction with ZN staining, however, will usually produce an early tissue diagnosis and enable prompt treatment to be instigated. In the case a testicular tumour is detected on FNA, immediate surgery with excision of needle track can follow. ²⁰

Conclusion

TB is the leading cause of chronic granulomatous epididymo-orchitis in many parts of the world. It is commonly mistaken as a testicular tumour both clinically and radiologically. FNA is a minimally invasive modality which can provide quick diagnosis facilitating medical treatment. Hence, unnecessary orchidectomy can usually be avoided.