Primary Tubercular ulcer in Glans Penis mimicking neoplastic lesion

Tuberculosis is a very common disease especially in developing countries but primary tuberculosis of penis is extremely rare. Here we are presenting a case of Primary tuberculosis of glans penis of 82 years male.


Introduction
More than 30% of the global population is affected by Tuberculosis (TB) and Eighty percent of all incident TB cases were found in 22 countries, with more than half the cases occurring in 5 Southeast Asian countries.The global case fatality rate was above 20% but exceeded 50% in some African countries with high HIV rates 1 .Extra-pulmonary tuberculosis is notorious for causing diagnostic difficulties, especially when present in the absence of proven pulmonary tubercular lesion.Tuberculosis may mimic neoplastic processes in various sites and still a major cause of morbidity in developing countries like INDIA, but tuberculosis of the glans penis is very rare.Till 1999, only 161 cases of penile tuberculosis were reported 2, 3 .The genitourinary (GU)tract is the most common site for extra pulmonaryTB, with the most frequently affected sites within the GU tract being the epididymis (42%), seminal vesicles (23%), prostate (21%), testes (15%) and vas deferens (12%) in males, and the fallopian tubes in females 4,5 .
In 1848, Fournier described the first case of penile tuberculosis 6 .In 1870 Soioweitschnik reported a next case of penile tuberculosis 7 .
Case Report A 82 years Hindu, married male from Chinsurah , Hoogly, West Bengal ,India presented with 1.5x1.5 cm ulcer in the glans penis covered with white slough with a punched out margin (fig- 1).The patient was responded on three weeks of antitubercular drugsand the lesion was healed by six months.

Discussion
The primary tubercular lesion in glans penis is rare.The primary cases can occur as a complication of ritual circumcision, during coital contact with the disease already present in the female gen-ital tract, or even from infected clothing  [12][13][14][15][16] .
Recently, the prevalence of TB in developing Primary Tubercular ulcer in Glans Penis mimicking neoplastic lesion 228

Fig-I Showing ulcer in the glans penis Fig-II-Photo micrograph showing tubercular granuloma with acid fast bacilli (inset)
countries has had a declining trend 17 .Any ulcer in the penis must be excluded for tuberculosis whether provocative factors present or not.Tuberculosis of penis may affect the skin, glans or cavernous bodies.In most cases, the lesion appears as a superficial ulcer on the glans or around the corona.TB chancre is usually associated with supprative lymph node, which is not found in this case.This case may be a papulonecrotictuberculoid type of lesion.The importance of biopsy in the diagnosis of chronic genital ulcer is important to exclude neoplastic lesion and start of early man-agement as well as to prevent spread of disease in the society.

Conclusion
Though incidence is rare the primary tuberculosis of glans penis must be excluded if one presented with unhealthy non healing ulcer in penis at any age as the lesion can be completely cured by conservative treatment.It may lead to detection of tubercular lesion in the genital tract of female counter part thus reducing the social problem.
Routine investigation of blood shows R.B.C-N o r m o c y t i c & N o r m o c h r o m i c , P l a t e l e t -Adequate,TLC-Within normal limit, Haemoglobin -11.0 gm/dl, ESR-40 mm/1 st hour.V.D.R.L-Nonreactive, HIV-Negative, Blood sugar (fasting)-79mg/dl, Blood sugar(PP)-109mg/dl, Blood urea-29mg/dl, Serum Creatinine-0.9mg/dl.X-ray chest -NAD.KOH preparation from ulcer show no fungal spore or hyphae.On Gram staining no specific bacteria identified (though the patient received antibiotics before gram staining).sputumA.F.B-Not Found.Biopsy was taken from the ulcerated lesion .Base of ulcer covered with fibrin .Underneath fibro collagenous tissue infiltrated by lymphocytes and histocytes, presence of epithelioid granuloma.Z.N staining shows presence of Acid fast bacilli(fig-II).