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Malakoplakia of the Testis and Its Relationship to Granulomatous Orchitis

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Malakoplakia of the Testis and Its Relationship to Granulomatous Orchitis J Clin Pathol: first published as 10.1136/jcp.33.7.670 on 1 July 1980. Downloaded from J Clin Pathol 1980;33:670-678 Malakoplakia of the testis and its relationship to granulomatous orchitis JOHN McCLURE From the Department of Pathology, The Queen's University of Belfast, Institute of Pathology, Grosvenor Road, Belfast, Northern Ireland, UK SUMMARY The chance finding of two cases of undiagnosed malakoplakia in the files of the Depart- ment of Pathology, Queen's University Belfast prompted a systematic study of all cases of inflam- matory testicular and epididymal disease diagnosed in that department during a 43-year period from 1934 to 1977. A total of 71 cases was studied, and no additional example of malakoplakia was found. In the Belfast collection, there is one other example of testicular malakoplakia and therefore a total of three cases in 74 examples of inflammatory testicular and epididymal disease (4 3 incidence). In the series there were 10 cases of granulomatous disease (I3 5 %). The world literature on testicular malakoplakia has been reviewed, and typical and atypical features have been determined. Also a comparison has been made between testicular malakoplakia and granulomatous orchitis, and the relationship between these conditions is discussed. Malakoplakia is an uncommon condition described above and a survey of the world literature are initially by Michaelis and Gutmann' and character- presented herein. ised by von Hansemann.2 Malakoplakia is probably a chronic inflammatory process, and the most com- Material and methods http://jcp.bmj.com/ monly affected site is the urinary bladder although involvement of extravesical sites is being reported All cases of inflammatory disease of the testis and with increasing frequency. Such sites include kidneys, epididymis diagnosed in the Department of Pathol- urinary pelvis and ureters,3 testis,4 prostate,7 8 and ogy, Queen's University Belfast during the period colon.9 1934 to 1977 were reviewed. A total of 74 cases was Malakoplakia is characterised by the presence of studied. The cases were grouped by the anatomical large cells with abundant, eosinophilic cytoplasm site of the inflammatory process (ie, involvement of on September 30, 2021 by guest. Protected copyright. (von Hansemann cells). In their cytoplasm there are epididymis and testis, testis only, and epididymis typical inclusions called Michaelis-Gutmann (MG) only) and by the character of the inflammatory bodies. These range from 2 to 10 ,um in diameter and process (ie, acute, acute and chronic, chronic, give a basophilic reaction with haematoxylin dye. granulomatous, and malakoplakic). These groupings Special stains reveal the presence of calcium and are displayed in the Table. Cases of tuberculosis sometimes iron salts. Frequently MG bodies have a were excluded. concentric laminated (targetoid or 'owl's eye') Fresh sections of all available blocks were cut and appearance. stained with haematoxylin and eosin (HE). Examples The chance finding of two cases of testicular of granulomatous disease and suspected examples of malakoplakia in the files of the Department of malakoplakia were also stained with von Kossa, Pathology, Queen's University Belfast prompted a periodic acid Schiff (PAS), Ziehl Nielsen (ZN), systematic review of all cases of inflammatory and alizarin red S, Perl's Prussian blue, the Gram stain, testicular disease in an attempt to discover further and the Warthin-Starry method. examples of malakoplakia. The results of this review, detailed case histories, and histopathological findings Case reports of the two cases oftesticular malakoplakia mentioned CASE I Received for publication 29 October 1979 A 55-year-old man was admitted to hospital with a 670 J Clin Pathol: first published as 10.1136/jcp.33.7.670 on 1 July 1980. Downloaded from Malakoplakia of the testis and its relationship to granulomatous orchitis 671 Table Character of inflammatory response in relation to anatomical site Cbaracter of inflammation Anatomical site Total Testis and epididymis Testis only Epididymis only Acute 3 5 6 14 (18-9%) Acute/chronic 12 3 6 21 (283 %) Chronic 6 10 10 26 (35 0%) Granulomatous 1 9 0 10 (13-5%) Malakoplakic 0 3 0 3 ( 4-3%) history of pain in the left testis for four weeks, and geneous, measuring 50 x 30 x 40 mm. Histo- pain on micturition and frequency for five weeks. logically, in some areas, the tubular architecture was Clinical examination revealed a firm, tender swelling completely replaced by a cellular infiltrate composed in the left side of the scrotum with enlarged tender largely of macrophages admixed with a smaller left inguinal lymph nodes. Rectal examination number of lymphocytes (Fig. 1). Many of the revealed a firm, enlarged prostate. macrophages contained faintly basophilic Michaelis- Routine haematological and biochemical tests Gutmann (MG) bodies, generally of nuclear size were within normal limits. Urine cultures revealed a (Fig. 2). Occasional extracellular MG bodies were significant growth of Escherichia coli on two occa- seen. Histochemically, the MG bodies reacted sions. The sputum was found to contain acid and positively with the PAS, alizarin red S, and von alcohol fast bacilli (AAFB) on one occasion (the Kossa techniques. A negative reaction was obtained urine was free of AAFB). There was a history of with Perl's Prussian blue method. The application of pulmonary tuberculosis in 1959. Currently, the Gram and ZN stains failed to reveal the presence of chest x-ray showed left apical calcification but no bacteria. sign of active disease. In many other areas, there was a somewhat Exploration of the scrotum resulted in removal of granulomatous appearance imparted by von Hanse- the left testis and epididymis (weight 60 g). The cut mann cells containing MG bodies probably contained surface of the testis was yellow-brown and homo- within a persisting tubular framework (Fig. 3). http://jcp.bmj.com/ on September 30, 2021 by guest. Protected copyright. Fig. 1 Accumulation of numerous von Hansemann cells (arrowed) against a background ofreplacement of the tubular testicular architecture by granulation tissue. (Haematoxylin and eosin x 200). J Clin Pathol: first published as 10.1136/jcp.33.7.670 on 1 July 1980. Downloaded from 672 McClure S...A.. .."......" ... AO ..::4 A.,...w.F.- ... Fig. 2 A Michaelis-Gutmann (MG) body is indicated in the cytoplasm of a von JIansemann cell. It shows a typical targetoid appearance. (H and E x 1000). http://jcp.bmj.com/ |lWYX A-MRrVAS on September 30, 2021 by guest. Protected copyright. .4t. ~ ~ ~ *.ew;......... ..... ..... Fig. 3 Vague granulomatou* appearance dlle to the presence of von Hansemann cells within a pe} sistings, tubular framework. The granulomatou* structures are delineated by arrow*. (H and E x 400). J Clin Pathol: first published as 10.1136/jcp.33.7.670 on 1 July 1980. Downloaded from Malakoplakia of the testis and its relationship to granulomatous orchitis 673 CASE 2 Results A 39-year-old man developed a painful, swollen right testis one month after an episode of pain on The survey of all cases of inflammatory testicular micturition and haematuria (urine culture revealed and epididymal disease revealed no additional cases a significant growth of Esch. coli). Haematological of malakoplakia. There were 10 examples of and biochemical indices were all normal, as was an granulomatous disease (Fig. 6). All these cases were intravenous pyelogram. There was nothing of ZN and Gram negative, and there were no foci of significance in the past medical history. He was caseation. Round intracytoplasmic inclusion bodies treated with antibiotics for the testicular swelling were noted in seven cases (Fig. 7). These structures initially with good effect. The testicular swelling were PAS-positive and showed some variation in recurred after another month, and right orchi- shape and size but they were generally of nuclear dectomy was performed. The orchidectomy specimen size. They reacted negatively with the von Kossa and weighed 111 g, and the cut surface was pale and alizarin red S techniques. These inclusions were homogeneous. Histologically, there was a vaguely plentiful in one case and only occasionally seen in the granulomatous appearance with poor delineation of other six. In addition, many cells contained fine groups of von Hansemann type cells containing intracytoplasmic PAS-positive droplets. Structures Michaelis-Gutmann bodies and apparently based with the morphological and histochemical charac- on tubular structures. Centrally, these structures teristics of the Michaelis-Gutmann body were not contained acute inflammatory cells (Fig. 4). There identified in any of the cases. Multinucleated giant was a fairly prominent lymphocyte infiltrate and cells were noted in three cases. These exhibited both some background fibrosis. The MG bodies reacted central and peripheral nuclear distribution, occupied positively with the alizarin red S, von Kossa, and central positions in the granulomata, and were not PAS methods (Fig. 5). The reaction with Perl's associated with caseation. Prussian blue was negative, and bacteria were not The remaining cases in the series exhibited either visualised with the Grarm or ZN methods. acute inflammatory changes (18 9°/,), acute and http://jcp.bmj.com/ on September 30, 2021 by guest. Protected copyright. ~~~~....~~~~~~~~~~1-. .1 Fig. 4 Vaguely granulomatous structures probably based on the pre-existing tubular framework corn posed peripherally of von Hansemann cells and centrally of acute inflammatory cells. (H and E x 200). J Clin Pathol: first published as 10.1136/jcp.33.7.670 on 1 July 1980. Downloaded from 674 McClure Fig. S An extracellular MG body is indicated by the arrow. (H and E x 1000). http://jcp.bmj.com/ on September 30, 2021 by guest. Protected copyright. Fig. 6 This is the typical histological pattern ofgranulomatous orchitis. (H and E x 200). J Clin Pathol: first published as 10.1136/jcp.33.7.670 on 1 July 1980. Downloaded from Malakoplakia of the testis and its relationship to granulomatous orchitis 675 L.0 .....
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