Prostatic malacoplakia: report of two cases and review of the... Alan C, Irkilata C, Ors O, Zor M, Peker AF

Balkan Military Medical Review
10, 49-51 (2007)
BALKAN
Military Medical
REVIEW
Case Report
Prostatic malacoplakia: report of two cases and review of the literature
Alan C, Irkilata C, Ors O, Zor M, Peker AF
Gulhane Military Medical Academy, School of Medicine, Department of Urology, Ankara, Turkey
Abstract. Transrectal ultrasonography guided
prostate biopsy was performed to two patients who
had increased levels of prostate specific antigen and
solid nodules in digital rectal examination. Here we
present two cases with prostatic malacoplakia which
diagnosed by histopathological examination and,
related review of the literature.
Key words: Prostatic malacoplakia, transrectal
ultrasonography, histopathological examination.
____________________________________________
60 gr. Transrectal ultrasonography (TRUS) showed
a hypoecoic area on the left peripheral zone, and
systematic prostate needle biopsy was performed.
Histological examination of the pathologic specimen was performed from the suspicious area on
the left prostate lobe; and later it was revealed as
prostatic malacoplakia. Cystoscopic examination
was unremarkable except prostatic hyperplasia.
Significant clinical improvement was obtained
with one-month oral ciprofloxacin treatment.
Case 2
Malacoplakia is a rare granulomatous inflammatory disease. Although it occurs mostly in the genitourinary system it may also occurs other places
than urinary system [1]. It is rarely reported in
prostate. In large series of studies prostate involvement is reported as 7% [2]. Macrophages
with eosinophilic inclusion granules and extended
cytoplasm are called as Michaelis-Gutmann bodies
and these are the characteristic cytological findings
of the malacoplakia [3]. However, histopathological features mostly let the definitive diagnosis;
sometimes the differential diagnosis from prostatic
carcinoma can be hard due to its clinical and histological features [1]. In this study, we reported two
prostatic malacoplakia cases, because of their rarity and their importance in the differential diagnosis from prostatic carcinoma.
Case 1
A 68 year-old male patient admitted to our clinic
with difficulty in urination. In the digital rectal
examination (DRE), left prostate lobe was solid
and fixed. Other physical examination findings
were unremarkable. Routine biochemical blood
tests were normal except serum prostate specific
antigen (PSA) level was 9.4 ng/ml (normally 0.22.6 ng/ml). E. coli was isolated in urine culture.
Ultrasonographic examination of the urinary system revealed normal except a prostate volume of
Correspondence to: Cabir Alan, MD, e-mail: cabir1@yahoo.com
A 70 year-old male patient admitted to the internal
medicine specialist with tiredness and loss of appetite. The patient was given a medical treatment for
upper respiratory system infection. At the admission the patient did not have active urological
symptoms. But DRE showed a solid nodular left
prostate lobe. Serum PSA level was 3.6 ng/ml,
erythrocyte sedimentation rate was 98/hour and the
other biochemical blood tests was normal. Upper
urinary system ultrasonography was normal and
prostate volume was 162 gr. The cystoscopy was
unremarkable except severe prostatic trilobular
hyperplasia. TRUS revealed a hypoecoic area at
the left peripheral zone of the prostate. Systematic
prostatic needle biopsy was performed. The pathological examination of biopsy material, reported as
prostatic malacoplakia. Significant clinical improvement was obtained with one-month oral
trimethoprim-sulfomethoxazole treatment.
Discussion
Malacoplakia is a granulomatous disease which
may occur at various tissues, but especially seen in
the urinary system. It was first described in 1902
by Michaelis and Gutmann. It is a benign, chronic
and inflammatory disease, and characterized by
granuloma formation. Macrophages forming
granulomas have extensive eosinophilic granular
cytoplasm. Macrophage cytoplasm and interstitial
50
concentric lamellae contains 5-10 micron bodies in
size and called as Michaelis and Guttmann bodies.
These bodies are bacterial debris materials, digested inside phagolysosomes [4]. Although the
exact etiology of malacoplakia is not known, the
most probable hypothesis suggested is abnormal
macrophage response due to a reduction in lysosomal function [5,6]. It is suggested that the
phagocytic ability of macrophages are normal but
there is a decrease in the break down of the organism phagocyted due to a decrease in the intracellular guanosine monophosphate levels and bglucoronidase release [7]. The concomitance of the
disease with AIDS, renal transplantation, leukemia,
tuberculosis, sarcoidosis, allergic diseases, cytotoxic chemotherapies and malignities supports the
hypothesis that immune response is altered in the
etiology of malacoplakia [8]. Malacoplakia is diagnosed only by histopathological examination.
The patognomonic Michaelis Gutmann bodies are
the last step in the destruction of bacteria and they
are suggested to be the result of phagolysosomal
integration [7,9]. The staining of the bodies with
iron and von Kossa stains supports that idea (Figures 1,2 and 3).
Balkan Military Medical Review
Vol. 10, No. 1, January 2007
Figure 2. Michaelis Gutmann bodies with iron stain
Clinical findings are various depending on the
affected areas. Bladder involvement causes mainly
bladder irritation and hematuria [7,12,13]. Ureteric
malacoplakia can cause stricturing and obstruction
[14]. In the upper urinary system involvement the
symptoms are colic pain, fever and tumor, which
are due to the enlargement of renal parenchyma. In
64% of patients the disease affects both kidneys
[15] and can eventually be fatal. A recent article
reported intense uptake of the radionuclide
67
gallium citrate in renal parenchymal malacoplakia. As the radioactivity reduces after treatment with antibiotics, this form of imaging could
be used to monitor the response to therapy [16].
Figure 1. Michaelis Gutmann bodies with iron stain
The first case about prostatic malacoplakia had
been reported in 1958 by Carruthers [10] and less
than 100 cases have been reported up to date.
There is a strong correlation between malacoplakia
and urinary system infection. In recent studies it
has been determined that bacilliform organisms
(70-75% E. coli) are isolated in the urine cultures
more than 80-90 % of malacoplakia cases [7,11].
Urinary system malacoplakia generally develops in
women in their 4th or 5th decades. The femalemale ratio is 4/1. Most frequently bladder is involved in the urinary system (70%). Isolated upper
urinary system involvement and combined upper
and lower urinary system involvement are observed with 15% for both [12].
Figure 3. Michaelis Gutmann bodies with von Kossa
stain
Prostatic involvement causes prostatic enlargement, bladder outlet obstruction and related symptoms. Nodules in digital rectal examination,
hypoecoic lesions in TRUS can mimic prostatic
carcinoma [1,17]. In both of our cases, a hard nodule was palpated in the digital rectal examination
and the primary problem in one of our patients was
difficulty in urination. At the TRUS prior to biopsy
the lesion was observed as a hypoecoic area at the
sites where a hard nodule was palpated in DRE and
the subsequent histopathological examination of
the biopsy material revealed malacoplakia. Both of
our cases were HIV negative and there was no
Alan et al.: Prostatic malacoplakia
evidence of immune indeficiency.
The combinations of endoscopic and medical approaches are mostly used in the treatment of malacoplakia involving lower urinary system [6,18,19].
If positive urine cultures are determined, long term
antibiotherapy must be performed. On the other
side, if negative urine cultures are determined, long
term extended spectrum antibiotherapy, and/or
betanecole for 3-4 months can be performed alternatively. Betanecole increases the bactericidal
activity of the macrophages [5,6,12]. In our first
case, ciprofloxacin susceptible E. coli isolated in
the urine culture, and significant clinical improve-
51
ment was obtained with antibiotic treatment. In the
other case, trimethoprim-sulfomethoxazole treatment had been previously initiated, so urine culture
did not performed and the treatment continued.
As a summary, it is difficult to differentiate
prostatic malacoplakia from prostate carcinoma
both clinically and radiologically. Thus, malacoplakia should be considered in the differential
diagnosis of a patient who had a hard nodule at
DRE and a hypoecoic lesion at the TRUS of prostate. The histopathological examination should be
performed by taking appropriate material with fine
needle biopsy.
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