Visceral abscesses caused by Mycobacterium tuberculosis are being reported with increasing frequency in association with human immunodeficiency virus (HIV) infection and the acquired immunodeficiency syndrome (AIDS) [1]. We report a large tuberculous abscess of the prostate that resulted in urinary obstruction.

A 47-year-old man with AIDS presented to our center after a week of fever, perineal pain, and urinary hesitancy. His physical examination was notable for a temperature of 38.6 °C and a markedly enlarged, tender prostate. Urinalysis showed many leukocytes, and acute prostatitis was diagnosed. The patient was treated with antibacterial agents for 2 weeks without improvement, and his condition progressed to complete urinary obstruction requiring bladder catheterization. Transrectal ultrasonography showed a markedly enlarged prostate containing a collection of heterogeneous fluid. Ultrasound-guided needle aspiration yielded 60 mL of purulent fluid. An auramine-rhodamine fluorochrome stain of this fluid showed numerous acid-fast bacilli, and a subsequent mycobacterial culture grew M. tuberculosis. Mycobacterial blood culture results were negative. Results of chest roentgenography were within normal limits. After aspiration and initiation of antituberculous agents, all symptoms were promptly relieved. One year later, the patient remained well without recurrent symptoms.

Extrapulmonary tuberculosis occurs with increased frequency among HIV-infected persons [2]. Extrapulmonary sites are involved in 50% to 70% of patients with HIV infection and tuberculosis [1]. Tuberculous abscess formation, a rare phenomenon in the era before AIDS, also occurs much more frequency in these patients. Lupatkin and colleagues [1] found an 11% incidence of abscess formation among 43 patients with AIDS and tuberculosis treated at an urban hospital.

Four cases of tuberculous prostatic abscess have been described in the literature, all in men with AIDS [3-5]. Unlike our patient, none of these four patients presented with symptoms referable to the prostate. Like our patient, both of the patients who received a diagnosis before death [3, 4] had a tender prostate on physical examination, were diagnosed by transrectal ultrasonography, and improved after initiation of appropriate therapy. Three of these patients presented with disseminated disease [3, 5].

These cases highlight the fact that tuberculosis in patients with HIV infection is an entity distinct from that seen in HIV-negative patients. It behaves more like a high-grade bacterial infection, with bacteremia and metastatic "seeding" of visceral organs. Extrapulmonary and disseminated tuberculosis must be considered in the differential diagnosis of HIV-infected patients who present with fever or focal symptoms. Physical examination of men in whom this condition is suspected should include a digital rectal examination, followed by transrectal ultrasonography if the prostate is abnormal. Mycobacterial stains and cultures should be obtained as part of the analysis of prostatic abscess fluid.