J Infect Chemother 20 (2014) 726e728
Contents lists available at ScienceDirect
Journal of Infection and Chemotherapy journal homepage: http://www.elsevier.com/locate/jic
Case report
Urethral polyp-like lesions on prostatic urethra caused by Chlamydia trachomatis infection: A case report Takashi Muranaka a, Satoshi Takahashi b, *, Takaoki Hirose a, Atsuo Hattori c a
Department of Urology, Hokkaido Social Health Insurance Hospital, Sapporo, Japan Department of Urology, Sapporo Medical University School of Medicine, Sapporo, Japan c Department of Pathology, Hokkaido Social Health Insurance Hospital, Sapporo, Japan b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 12 February 2014 Received in revised form 16 June 2014 Accepted 3 July 2014 Available online 14 August 2014
Urethral polyp is one of differential diagnoses for the male patients complain of gross-hematuria and/or hematospermia. However, there have been limited numbers of case reports including infectious etiology. Here we reported clinical course and pathological findings of one rare case who was diagnosed and treated as urethral polyp-like lesions on the prostatic urethra caused by Chlamydia trachomatis infection. A 25 year-old man who had a past history of frequent sexual intercourse with unspecified female sexual partner visited the clinic. His chief complaint was gross-hematuria and hematospermia. Endoscopic findings showed that nonspecific hemorrhagic polyp-like lesions. To determine the pathological findings including malignant diseases and diagnosis, transurethral resection was performed. Because the pathological findings were similar to those of chlamydial proctitis, additional examination was done. As the results, nucleic acid amplification test of C. trachomatis in urine specimen was positive and immunohistochemical staining of specific chlamydia antigen in resected specimen was also positive. Treatment by orally minocyline 100 mg twice daily for 4 weeks was introduced. After the treatment, symptom was disappeared and nucleic acid amplification test of C. trachomatis in urine specimen turned to be negative. No recurrence was reported 2 years posttreatment. © 2014, Japanese Society of Chemotherapy and The Japanese Association for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.
Keywords: Chlamydia trachomatis Urethral polyp-like lesion Hematospermia
1. Introduction Urethral polyp is one of various differential diagnosis of gross- or microscopic hematuria and the morbidity rate of urethral polyp could not be negligible in the patients complain of gross- or microscopic hematuria [1,2]. Although its infectious etiology has been diverse, there have been few reports about urethral polyp caused by Chlamydia trachomatis to date. Here we report a rare case with urethral polyp-like lesions on prostatic urethra caused by C. trachomatis determined by histopathological findings and detection of nucleic acid. 2. Case report A 25 year-old man who complained of asymptomatic grosshematuria, urethral hemorrhage after urination and hematospermia visited the clinic. There was no other symptom and no abnormal
* Corresponding author. Department of Urology, Sapporo Medical University School of Medicine, S1, W16, Chuo-ku, Sapporo 060-8543, Japan. Tel.: þ81 011 611 2111; fax: þ81 011 612 2709. E-mail addresses: [email protected], [email protected], [email protected] (S. Takahashi).
findings on abdominal and genital lesions. Just one specific episode was that he had the history of unprotected sexual intercourse with unspecified female sexual partners in the past. Urinalysis in both voided bladder urine 1 and 2 showed normal findings. In his past history, the patient complained of asymptomatic gross-hematuria received medical examination including abdominal ultrasound and urinary cytological examination at the clinic 12 months before the visit and the medical examination showed no abnormal findings. After that, the patient has been aware of urethral hemorrhage after urination for 12 months and hematospermia for 6 months, however, he has not visited the clinic again since the last visit. In this visit, endoscopic examination showed hemorrhagic polyp on the prostatic urethra (Fig. 1a and b). No abnormal findings in the urinary bladder were observed. Abdominal CT showed no obvious abnormal findings except for a 2 cm size left renal cyst. Cytological examination of urine reported no atypical cells. Because there was some possibility of neoplastic tumor developed on prostatic urethra, transurethral resection of polyp was performed to determine pathological diagnosis. Due to the intraoperative rapid pathological test, the results indicated the follicular change and chronic inflammation of prostatic urethra, however,
http://dx.doi.org/10.1016/j.jiac.2014.07.002 1341-321X/© 2014, Japanese Society of Chemotherapy and The Japanese Association for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.
T. Muranaka et al. / J Infect Chemother 20 (2014) 726e728
727
Fig. 1. Endoscopic finding showed easy bleeding polyp lesion covered with specific findings like salmon roe on prostatic urethra, and the prostatic urethra of after treatment. a; Endoscopic findings showed that easy bleeding polyps developed in prostatic urethra. b; Endoscopic findings showed that salmon roe like polyp-like lesions (arrow). c; No polyplike lesions were observed in prostatic urethra.
lymphoproliferative diseases could not be ruled out. Then, the final pathological report showed chronic inflammation of prostatic urethra and no malignant findings. The patient was discharged postoperative day 7 without any troubles and he was observed regularly without any additional treatment (Fig. 2). Six months after the operation, the patient visited the clinic again. Hematospermia periodically occurred although no grosshematuria was observed. Urinalysis showed 5 to 10 white blood cells/high power field and no polyp-like lesion was identified by endoscopic examination. However, resected wound of prostatic urethra was delayed in healing and the lesion was likely to have a hemorrhage. As the results of the discussion between urologists and pathologist, both macroscopic and pathological findings could be similar to chlamydial proctitis so that urethral polyp-like lesion on prostatic urethra caused by C. trachomatis was mostly suspected. Therefore, re-examination was done. Then, nucleic acid amplification test of C. trachomatis in urine specimen was positive and immunohistochemical staining of specific chlamydial antigen in previous resected specimen was also positive. According to the results, treatment by orally minocyline 100 mg twice daily for 4 weeks was introduced. After the treatment, symptom was clearly disappeared. Nucleic acid amplification test of C. trachomatis in urine specimen turned to be negative and endoscopic finding showed the prostatic urethra was normalized 1 month after 4week antimicrobial chemotherapy (Fig. 1c). No recurrence was observed during one year after medical treatment. 3. Discussion There have been limited number of reports concerning urethral tumors and urethral polyps, and the etiology of the diseases has been still mostly unknown. The number of cases was relatively summarized in the following reports: Kuwata et al. [1] reported the
clinical pathological study on 34 cases of male benign urethral tumors and Furuya et al. [2] reported the clinical study on 25 cases of prostatic epithelial polyps in the prostatic urethra. Furuya et al. reported that urethral polyp lesions were found in 8% of the macroscopic hematuria cases. Chlamydial proctitis as a diagnosis for the present case is an infection to the rectal mucous membrane of C. trachomatis and the number of cases is currently increasing due to diversification of sexual activities. As a result, it is considered to be important as a discrimination disease from Chrohn's disease and lymphoproliferation disease [3,4]. As macroscopic finding of the Chlamydial proctitis, features include dense presence of defuse granular protuberances, redness, erosion and easily-hemorrhagic mucus membrane lesions, while pathohistological features include proliferation of lymphatic follicles and inflammatory cellular infiltration. These features are similar to the lesions in the prostatic urethra in the present case and provided a chance of diagnosis. Generally, polyp-like formation of granulation tissue by C. trachomatis infection is known to be rare, however, polyp-like formation of granulation tissue was detected in the present case. In LGV type, polyp-like formation of granulation tissue may be able to develop. However, we failed to determine the serovar. In addition, LGV type has been rarely detected in Japan to date. This was the most regrettable limitation of this case report. Furuya et al. [5] reported chlamydial seminal vesiculitis without symptoms of urethritis and epididymitis with which the major complaint was hematospermia, suggesting a possibility that the infection to the seminal vesicle is a source of the supply of C. trachomatis. In the present case, seminal vesicle might be also involved. That might be the reason why the local condition delayed in healing after transurethral resection and C. trachomatis as causative organism might be supplied from infected seminal vesicle.
Fig. 2. Histopathological findings of the resected specimens a: Hematoxylin and eosin staining with low power field showed lymphatic follicles (arrow) b: Hematoxylin and eosin staining with high power field showed infiltration of inflammatory cells and inclusion bodies (arrow) c: Immunohistochemical staining of specific chlamydial antigen showed positive brown color cells (arrow). (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)
728
T. Muranaka et al. / J Infect Chemother 20 (2014) 726e728
4. Conclusion
References
We experienced one case of urethral polyp-like lesions on prostatic urethra caused by C. trachomatis. As far as we searched, we did not find any report of urethral polyp caused by C. trachomatis infection. When male patients who are possible to have sexually transmitted infection visited clinic with complaint of hemotospermia or urethral hemorrhage, urethral polyp-like lesion can be one of different diagnosis. C. trachomatis can be one of infectious etiology for urethral polyp-like lesion and optimal antimicrobial chemotherapy can lead to cure successfully.
[1] Kuwata Y, Kuroda I, Yamaoka N, Yamamoto N, Soramoto S, Takenata I. Benign polypoid tumor of the male urethra: a report of 34 cases. Nishi Nihon Hinyokika 2000;62:207e10 [in Japanese]. [2] Furuya S, Ogura H, Shimamura S, Itoh N, Tsukamoto T, Isomura H. Clinical Manifestations of 25 patients with prostatic-type polyps in the prostatic urethra. Hinyokika Kiyo 2002;48:337e42 [in Japanese]. [3] Isozaki Y, Suzuki K, Matsuyama T, Matsumoto N, Nagao Y, Ishikawa T, et al. Three cases of Chlamydia trachomatis prostitis found by fecal occult blood. Gastroenterol Endosc 2009;51:1707e13. [4] Ootani A, Fujimoto K. Chlamydia trachomatis proctitis. Intestine 2011;15: 81e4. [5] Furuya R, Takahashi S, Furuya S, Takeyama K, Masumori N, Tsukamoto T. Chlamydial seminal vesiculitis without symptomatic urethritis and epididymitis. Int J Urol 2006;13:466e7.
Conflict of interest None.
Contents lists available at ScienceDirect
Journal of Infection and Chemotherapy journal homepage: http://www.elsevier.com/locate/jic
Case report
Urethral polyp-like lesions on prostatic urethra caused by Chlamydia trachomatis infection: A case report Takashi Muranaka a, Satoshi Takahashi b, *, Takaoki Hirose a, Atsuo Hattori c a
Department of Urology, Hokkaido Social Health Insurance Hospital, Sapporo, Japan Department of Urology, Sapporo Medical University School of Medicine, Sapporo, Japan c Department of Pathology, Hokkaido Social Health Insurance Hospital, Sapporo, Japan b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 12 February 2014 Received in revised form 16 June 2014 Accepted 3 July 2014 Available online 14 August 2014
Urethral polyp is one of differential diagnoses for the male patients complain of gross-hematuria and/or hematospermia. However, there have been limited numbers of case reports including infectious etiology. Here we reported clinical course and pathological findings of one rare case who was diagnosed and treated as urethral polyp-like lesions on the prostatic urethra caused by Chlamydia trachomatis infection. A 25 year-old man who had a past history of frequent sexual intercourse with unspecified female sexual partner visited the clinic. His chief complaint was gross-hematuria and hematospermia. Endoscopic findings showed that nonspecific hemorrhagic polyp-like lesions. To determine the pathological findings including malignant diseases and diagnosis, transurethral resection was performed. Because the pathological findings were similar to those of chlamydial proctitis, additional examination was done. As the results, nucleic acid amplification test of C. trachomatis in urine specimen was positive and immunohistochemical staining of specific chlamydia antigen in resected specimen was also positive. Treatment by orally minocyline 100 mg twice daily for 4 weeks was introduced. After the treatment, symptom was disappeared and nucleic acid amplification test of C. trachomatis in urine specimen turned to be negative. No recurrence was reported 2 years posttreatment. © 2014, Japanese Society of Chemotherapy and The Japanese Association for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.
Keywords: Chlamydia trachomatis Urethral polyp-like lesion Hematospermia
1. Introduction Urethral polyp is one of various differential diagnosis of gross- or microscopic hematuria and the morbidity rate of urethral polyp could not be negligible in the patients complain of gross- or microscopic hematuria [1,2]. Although its infectious etiology has been diverse, there have been few reports about urethral polyp caused by Chlamydia trachomatis to date. Here we report a rare case with urethral polyp-like lesions on prostatic urethra caused by C. trachomatis determined by histopathological findings and detection of nucleic acid. 2. Case report A 25 year-old man who complained of asymptomatic grosshematuria, urethral hemorrhage after urination and hematospermia visited the clinic. There was no other symptom and no abnormal
* Corresponding author. Department of Urology, Sapporo Medical University School of Medicine, S1, W16, Chuo-ku, Sapporo 060-8543, Japan. Tel.: þ81 011 611 2111; fax: þ81 011 612 2709. E-mail addresses: [email protected], [email protected], [email protected] (S. Takahashi).
findings on abdominal and genital lesions. Just one specific episode was that he had the history of unprotected sexual intercourse with unspecified female sexual partners in the past. Urinalysis in both voided bladder urine 1 and 2 showed normal findings. In his past history, the patient complained of asymptomatic gross-hematuria received medical examination including abdominal ultrasound and urinary cytological examination at the clinic 12 months before the visit and the medical examination showed no abnormal findings. After that, the patient has been aware of urethral hemorrhage after urination for 12 months and hematospermia for 6 months, however, he has not visited the clinic again since the last visit. In this visit, endoscopic examination showed hemorrhagic polyp on the prostatic urethra (Fig. 1a and b). No abnormal findings in the urinary bladder were observed. Abdominal CT showed no obvious abnormal findings except for a 2 cm size left renal cyst. Cytological examination of urine reported no atypical cells. Because there was some possibility of neoplastic tumor developed on prostatic urethra, transurethral resection of polyp was performed to determine pathological diagnosis. Due to the intraoperative rapid pathological test, the results indicated the follicular change and chronic inflammation of prostatic urethra, however,
http://dx.doi.org/10.1016/j.jiac.2014.07.002 1341-321X/© 2014, Japanese Society of Chemotherapy and The Japanese Association for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.
T. Muranaka et al. / J Infect Chemother 20 (2014) 726e728
727
Fig. 1. Endoscopic finding showed easy bleeding polyp lesion covered with specific findings like salmon roe on prostatic urethra, and the prostatic urethra of after treatment. a; Endoscopic findings showed that easy bleeding polyps developed in prostatic urethra. b; Endoscopic findings showed that salmon roe like polyp-like lesions (arrow). c; No polyplike lesions were observed in prostatic urethra.
lymphoproliferative diseases could not be ruled out. Then, the final pathological report showed chronic inflammation of prostatic urethra and no malignant findings. The patient was discharged postoperative day 7 without any troubles and he was observed regularly without any additional treatment (Fig. 2). Six months after the operation, the patient visited the clinic again. Hematospermia periodically occurred although no grosshematuria was observed. Urinalysis showed 5 to 10 white blood cells/high power field and no polyp-like lesion was identified by endoscopic examination. However, resected wound of prostatic urethra was delayed in healing and the lesion was likely to have a hemorrhage. As the results of the discussion between urologists and pathologist, both macroscopic and pathological findings could be similar to chlamydial proctitis so that urethral polyp-like lesion on prostatic urethra caused by C. trachomatis was mostly suspected. Therefore, re-examination was done. Then, nucleic acid amplification test of C. trachomatis in urine specimen was positive and immunohistochemical staining of specific chlamydial antigen in previous resected specimen was also positive. According to the results, treatment by orally minocyline 100 mg twice daily for 4 weeks was introduced. After the treatment, symptom was clearly disappeared. Nucleic acid amplification test of C. trachomatis in urine specimen turned to be negative and endoscopic finding showed the prostatic urethra was normalized 1 month after 4week antimicrobial chemotherapy (Fig. 1c). No recurrence was observed during one year after medical treatment. 3. Discussion There have been limited number of reports concerning urethral tumors and urethral polyps, and the etiology of the diseases has been still mostly unknown. The number of cases was relatively summarized in the following reports: Kuwata et al. [1] reported the
clinical pathological study on 34 cases of male benign urethral tumors and Furuya et al. [2] reported the clinical study on 25 cases of prostatic epithelial polyps in the prostatic urethra. Furuya et al. reported that urethral polyp lesions were found in 8% of the macroscopic hematuria cases. Chlamydial proctitis as a diagnosis for the present case is an infection to the rectal mucous membrane of C. trachomatis and the number of cases is currently increasing due to diversification of sexual activities. As a result, it is considered to be important as a discrimination disease from Chrohn's disease and lymphoproliferation disease [3,4]. As macroscopic finding of the Chlamydial proctitis, features include dense presence of defuse granular protuberances, redness, erosion and easily-hemorrhagic mucus membrane lesions, while pathohistological features include proliferation of lymphatic follicles and inflammatory cellular infiltration. These features are similar to the lesions in the prostatic urethra in the present case and provided a chance of diagnosis. Generally, polyp-like formation of granulation tissue by C. trachomatis infection is known to be rare, however, polyp-like formation of granulation tissue was detected in the present case. In LGV type, polyp-like formation of granulation tissue may be able to develop. However, we failed to determine the serovar. In addition, LGV type has been rarely detected in Japan to date. This was the most regrettable limitation of this case report. Furuya et al. [5] reported chlamydial seminal vesiculitis without symptoms of urethritis and epididymitis with which the major complaint was hematospermia, suggesting a possibility that the infection to the seminal vesicle is a source of the supply of C. trachomatis. In the present case, seminal vesicle might be also involved. That might be the reason why the local condition delayed in healing after transurethral resection and C. trachomatis as causative organism might be supplied from infected seminal vesicle.
Fig. 2. Histopathological findings of the resected specimens a: Hematoxylin and eosin staining with low power field showed lymphatic follicles (arrow) b: Hematoxylin and eosin staining with high power field showed infiltration of inflammatory cells and inclusion bodies (arrow) c: Immunohistochemical staining of specific chlamydial antigen showed positive brown color cells (arrow). (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)
728
T. Muranaka et al. / J Infect Chemother 20 (2014) 726e728
4. Conclusion
References
We experienced one case of urethral polyp-like lesions on prostatic urethra caused by C. trachomatis. As far as we searched, we did not find any report of urethral polyp caused by C. trachomatis infection. When male patients who are possible to have sexually transmitted infection visited clinic with complaint of hemotospermia or urethral hemorrhage, urethral polyp-like lesion can be one of different diagnosis. C. trachomatis can be one of infectious etiology for urethral polyp-like lesion and optimal antimicrobial chemotherapy can lead to cure successfully.
[1] Kuwata Y, Kuroda I, Yamaoka N, Yamamoto N, Soramoto S, Takenata I. Benign polypoid tumor of the male urethra: a report of 34 cases. Nishi Nihon Hinyokika 2000;62:207e10 [in Japanese]. [2] Furuya S, Ogura H, Shimamura S, Itoh N, Tsukamoto T, Isomura H. Clinical Manifestations of 25 patients with prostatic-type polyps in the prostatic urethra. Hinyokika Kiyo 2002;48:337e42 [in Japanese]. [3] Isozaki Y, Suzuki K, Matsuyama T, Matsumoto N, Nagao Y, Ishikawa T, et al. Three cases of Chlamydia trachomatis prostitis found by fecal occult blood. Gastroenterol Endosc 2009;51:1707e13. [4] Ootani A, Fujimoto K. Chlamydia trachomatis proctitis. Intestine 2011;15: 81e4. [5] Furuya R, Takahashi S, Furuya S, Takeyama K, Masumori N, Tsukamoto T. Chlamydial seminal vesiculitis without symptomatic urethritis and epididymitis. Int J Urol 2006;13:466e7.
Conflict of interest None.
