A Spanish 26-year-old man presented with a painful subcutaneous nodule on his penis, which had grown during the past 2 weeks. Despite the fact that the patient was married, he admitted to being a regular user of female prostitution but denied having had extramarital sex for the past 6 months.
The physical examination revealed an uncircumcised patient in good general health with a well demarcated and erythematosus subcutaneous nodule localized on the dorsum of the penis. Neither other skin changes in any other part of the body surface nor palpable lymph nodes in the inguinal region could be observed. The patient had been diagnosed with an abscess of the penis by his general practitioner, for which treatment with oral amoxicillin had been prescribed (500 mg every 8 hours for 10 days). As no improvement could be observed, he asked for assistance in our department, where the same diagnosis was made, and the treatment was extended for 7 days more.
Two weeks later, the patient showed a painful ulcer at the same location, 7 cm in diameter with granulation tissue and a lilaceous border (Fig. 1). The ulcer did not affect the urinary function of the corpus cavernosum or the urethra. Besides, no lymph nodes were palpable in the inguinal region.
Routine laboratory investigations, including full blood count, biochemical profile, urine test, and liver function test were normal, and syphilis, lymphogranuloma venereum, and HIV were ruled out. Two punch biopsies were obtained from the ulcer, one for histopathological study and the other for microbiological culture.
The histopathological examination showed granulomatous inflammation with abundant Langerhans giant cell response (Fig. 2). No acid-fast bacilli were found in the specimens by Ziehl–Neelsen staining. However, after 4 weeks, the samples sent to microbiologic culture were positive for Mycobacterium tuberculosis.
The tuberculin test was negative, and the chest radiograph was normal.
Eventually, a diagnosis of primary cutaneous tuberculosis of the penis was done.
The patient received a treatment consisting of triple antituberculous therapy (rifampicin 600 mg + isoniazid 200 mg + pyrazinamide 500 mg per day) for 2 months and isoniazid 200 mg + rifampicin 600 mg for 4 months.
Ten months later, the ulcer was completely healed, although it had left an atrophic scar that caused a curvature and deformity of the penis, which would require reconstructive surgery (Fig. 3).
Some years ago, primary tuberculosis was more common than present, as a result of the practice of the rite of circumcision in developed countries, which was normally carried out with material contaminated by the Koch bacillus. Currently, its diagnosis is unusual.
Although the involvement of the penis in primary infection with Mycobacterium tuberculosis is exceptional, at present, more cases are reported in Japan than in the rest of the world. In addition, migratory movements like those produced in the past 20 years between the borders of Afghanistan and Iran because of wars have led to describe new cases. Nevertheless, its reporting in developed countries is extremely rare.
In 1946, Lewis and colleagues found 110 cases of tuberculosis of the penis by following a review of the literature of the time, of which 89 cases were primary, 8 secondary, 9 had a clearly unknown origin, 1 was undetermined, and 3 were a result of the hematogenous dissemination of disease.1 Of the 89 cases classified as primary, 72 were the result of the rite of circumcision with contaminated material. The remaining 17—except 2 of them, unrelated to the rite of circumcision—had been caused by sexual intercourse with infected women. From 1971 to 2007, only 177 cases of primary tuberculosis of the penis have been reported,2,3,4 and just a few since then, until today.
In this case, the lesion was primary, but we cannot determine the cause of transmission. Given that the patient is a regular user of female prostitution, the infection must be related to the sexual practice, whereas lymphatic dissemination or similar are ruled out. Both the microbiologic confirmation and the excellent response to the treatment confirmed the infectious etiology of the lesion.
1. Lewis EL. Tuberculosis of the penis: A report of 5 new cases, and complete review of the literature. J Urol 1946; 56:737–745.
2. Annobil SH, al-Hilfi A, Kazi T. Primary tuberculosis of the penis in an infant. Tubercle 1990; 71:229–230.
3. Jeyakumar W, Ganesh R, Mohanram MS, et al.. Papulonecrotic tuberculids of the glans penis: Case report. Genitourin Med 1998; 64:130–132.
4. Nishigori C, Taniguchi S, Hayakawa M, et al.. Penis tuberculides: Papulonecrotic tuberculides on the glans penis. Dermatologica 1986; 172:93–97.