Casuistry: Disseminated tuberculosis?

A young immigrant from Guatemala presents to a clinic with shortness of breath and abnormal lung findings. Is he another case of disseminated tuberculosis, which is common in his home country?

Case presentation: Distinct pulmonary symptoms

What is the diagnosis according to symptoms?

Against the background that the young man entered the USA from Guatemala to find work, the suspicion of disseminated tuberculosis increases. Guatemala is one of the countries in the world with a comparatively high tuberculosis incidence of 21 per 100,000 inhabitants.

In addition to the cavitary lung lesions, radiology revealed a large mass of tissue extending into the left atrium. The laboratory also suggested inflammation; urobilinogen was elevated. Tests for COVID-19, influenza, RSV and HIV were negative.

According to the assessment of the emergency physicians on site, the patient fulfilled criteria for sepsis and was treated initially with a broad-spectrum antibiotic. A subsequent bronchoscopy and a transthoracic echocardiogram both confirmed tissue masses in the left lung and left atrium. In addition, an enlarged, painless testis was noticed in the renewed clinical examination. According to the patient, this condition had also existed for several months.

How would you decide in this case? Is this a case of disseminated tuberculosis or organ tuberculosis? What else would you clarify by differential diagnosis?

The resolution: A fatal error

Contrary to what the first set of symptoms suggested, the young man did not suffer from tuberculosis. Instead, the patient was presented to the urology clinic because of the testicular findings. An ultrasound performed at the clinic found an 8 x 4 x 5 cm tumour mass on the right testicle. Four days later, a radical orchiectomy was performed. At the same time, the tissue mass from the lung was identified as a metastasis of a primary testicular tumour after biopsy. Another metastasis was found in the right kidney.

Due to the heavy involvement of the heart and the high metastatic burden, the patient received 5 days of platinum-based chemotherapy without further surgical intervention. Although there was a decrease in metastasis size, the patient generally tolerated the therapy very poorly. His condition also deteriorated rapidly. Finally, the young man died as a result of acute renal and liver failure.

Differential diagnosis: Testicular tumour in a young man

The present case of a 22-year-old man from Guatemala presented the attending physicians with a diagnostic dilemma. On the one hand, the observed symptoms fit very well with tuberculosis, an infectious disease which has a high incidence (21/100,000) in the patient's home country.

In this case on the other hand, testicular carcinoma (0.6/100,000), which is much rarer in Guatemala, had to be considered, a neoplasia whose age peak is in the group of adolescents and young men up to 35 years.

For the young man, however, it was fatal that his metastasised testicular tumour caused typical pulmonary symptoms of tuberculosis and had thus also put the physicians on the wrong track months before the acute emergency.

What could have gone better?

This case again shows how important the differential diagnosis "infectious disease versus neoplasia" is in young men. An earlier examination of the testicles might have made a quicker diagnosis and therapy possible and could have saved the 22-year-old's life.

In addition, physicians should also take care to explain to young men and adolescents the possibility of self-examination of the testicles ("palpation"). If the patient had been sufficiently informed about which palpation findings he should have consulted a physician about, it is very likely that he would not have lived with an enlarged, painless testicle for months or even several years.

Reference: Najdawi F. et al., Annals of Medicine and Surgery 72 (2021) 102975