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: [email protected] 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. Refrences 1. 2. 3. 4. 5. 6. 7. Scott D, Perrapato G, Carotthers C, Eugene S. Transrectal ultrasound and fine needle aspiration for malacoplakia of the prostate. J Urol 139:13211324, 1988. Kumon H, Furukowa M, Tsugawa M, Matsumura Y, Ohmori H. Prostatic malakoplakia: a case report with a review of 49 cases of malacoplakia of various sites in Japan. Acta Med Okayama 37:493-495, 1983. 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