Case of the Month - September 2010

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A 34 year old man presented to Alexandra Men’s clinic, Gauteng with a ‘Water Can’ penis. He had a 3 year history of genital ulceration and purulent discharge per urethra, with multiple discharge sinuses around the shaft of the penis. His past medical history included confirmed pulmonary TB 2 years previously, treated for 6 months with regimen 1. On clinical examination inguinal glands and testes were normal, there was no urethral discharge, but he had multiple sinuses on the glans penis.

The case was thoroughly investigated to rule out STIs such as syphilis, chancroid and Donovanosis. M-PCR was done from the genital swab taken and all organisms (HSV, Haemophilus ducreyi and Treponema pallidum) were negative including LGV. Serological tests for HSV-2 serology were positive, as was Chlamydia pneumoniae IgG at a titre of 1:128. Syphilis serology was negative. All urethral discharge STI pathogens (Chlamydia trachomatis, Neisseria gonorrhoeae and Mycoplasma genitalium) were negative except Trichomonas Vaginalis. He was treated with metronidazole 400mg bd and acyclovir 400mg tds for 7 days. Chlamydia pneumoniae titre may indicate previous exposure and was not treated.

At the time of presentation, sputum from the patient was smear-positive for acid-fast bacilli and despite regimen 2 TB treatment, he remained smear-positive after 2 months.
M. tuberculosis resistance testing was not performed. He developed persistent cough and marked weight loss. He eventually agreed to undergo HIV counselling and testing (HCT) and was found to be HIV-infected with a CD4 count of 181 cells/mL. Early initiation of ARV therapy was recommended and the patient referred to start ART.

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