Beyond the surface: a case report of penile tuberculosis as the first sign of miliary disease in a solid organ transplant recipient.

Background: Tuberculosis (TB) remains a major opportunistic infection in solid organ transplant recipients, with an incidence significantly higher than in the general population. Immunosuppression often leads to atypical and disseminated forms of TB, complicating timely diagnosis. Extrapulmonary TB can manifest in various genitourinary sites, but penile involvement is exceedingly rare, comprising less than 1% of urogenital TB cases. Case Summary: We report a confirmed case of penile TB in a 56-year-old abattoir worker with a history of renal transplant, who presented with a penile ulcer with cellulitis and systemic symptoms. Imaging revealed miliary pulmonary TB, confirmed on molecular testing from both respiratory and skin tissue samples. The patient was commenced on a four-drug anti-tuberculous regimen with dose modifications due to drug interactions with immunosuppressive medications. Clinical improvement with resolution of the penile lesion and systemic symptoms was noted. Conclusion: This case highlights the need for increased clinical suspicion for TB in immunosuppressed patients presenting with atypical genitourinary symptoms. Early recognition and prompt initiation of treatment, alongside careful adjustment of immunosuppression, are critical to achieving favorable outcomes. Given the rarity of penile TB and the complexity of its management in transplant recipients, this case contributes to the limited literature and underscores the importance of a multidisciplinary approach.