A man in Ireland earned the unpleasant distinction of developing an exceedingly rare infection on his penis—one that has a puzzling origin, but may be connected to his work with dead animals.
According to an article published in ASM Case Reports on Thursday, the 57-year-old man went to a hospital in Dublin after his penis became red, swollen, and painful over the course of a week. He also had a fever. Doctors promptly admitted him to the hospital and noted that he had received a kidney transplant 15 years prior. As such, he was on immunosuppressive drugs, which keep his body from rejecting the organ, but could also allow infections to run amok.
Initial blood work found hints of an infection, and the doctors initially suspected a bacterial skin infection (cellulitis) had taken hold in his nether region. So, they put him on some standard antibiotics for that. But his penis only got worse, redder, and more swollen. This prompted consultation with infectious disease doctors.
A more thorough review of the man’s case revealed that in the three months before his hospital visit, he had experienced fever, drenching night sweats, chills, loss of appetite, and weight loss. They also noted that he had a lot of dead animal exposure. He was born and raised on a farm in rural Ireland, worked as a butcher handling deer and occasionally cattle, and was an avid hunter who field-dressed game.
Dangerous disease
Given the systemic symptoms he mentioned in previous months, the doctors took computed tomography (CT) scans of his chest, abdomen, and pelvic region to investigate the cause. The images quickly revealed the answer; his lungs were speckled with seed-like nodules, characteristic of miliary tuberculosis.
Miliary tuberculosis (MTB) is a severe form of tuberculosis in which the instigating bacteria— Mycobacterium tuberculosis or potentially a relative that infects cows and deer, Mycobacterium bovis—spread widely through the body and create small lesions. The name “miliary” dates back to 1700, when a physician noted that the specks resembled millet seeds.
While Mycobacterium can spread through the air and are often found in the lungs, the bacteria can strike anywhere in the body. Still, penile tuberculosis is exceedingly rare. In fact, it’s uncommon to have tuberculosis erupt anywhere in the urinary and genital tracts. Among the infections that spring up in the region, penile infections account for less than 1 percent.
But, given the man’s lungs and his immunosuppressed status, the unusual presentation became their leading guess—and tests soon confirmed it. Mycobacterium were identified in the man’s respiratory tract, and penile tissue tested also showed the bacteria, though the testing couldn’t identify what species of Mycobacterium.
Treatment for tuberculosis requires a regimen of several antibiotics and takes months. In the man’s case, they customized his treatment with a 12-month, four-drug regimen that wouldn’t interfere with his transplant.
Still, the penile lesion got worse before it got better. He developed a large necrotic ulceration on the side of his penis, and his foreskin began to “break down.” Surgeons had to mechanically cut out the dead tissue. After 10 months, his infection appeared to have cleared, and his penile lesion had improved.
Unexplained exposure
It remains unclear how the man got the infection. He told doctors he wasn’t aware of coming in contact with any tuberculosis patients and wasn’t in settings where the bacteria normally spread, such as prisons. It’s possible that the bacteria had been lurking in his transplanted kidney.
However, doctors speculated that it could also have been due to his animal exposure. Deer and cows are known to spread M. bovis, and people who hunt and butcher animals are known to be at risk. These workers can become infected from inhaling it from the exhaled breath of an infected animal or from direct contact with an infected animal’s wounded tissue or body fluids, such as what happens during slaughtering.
It’s unclear if the man’s infection started in his lungs or on his penis. It’s possible he could have inhaled it first; the bacteria were clearly in his lungs. But he could have also picked up the bacteria on his hands while working and then spread it further while, for example, using the bathroom. The doctors note a similar situation called “Prosector’s wart,” when doctors or scientists conduct dissections or autopsies on tuberculosis-infected specimens, they can develop wart-like tuberculosis skin infections. The infections are often on the hands, but can occur anywhere on the body.
Tuberculosis has been found to spread in some surprising ways. The doctors noted a case report from the UK in 2001 in which a man developed penile tuberculosis and his partner developed uterine tuberculosis a year later, suggesting sexual transmission.
While it will remain a mystery how the man developed such a rare infection, there’s a happy ending for this case and others: “Encouragingly, all published cases of penile TB responded well to anti-TB therapy with full recovery,” the doctors conclude.
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