The Great Pretender: Xanthogranulomatous Prostatitis Mimicking Prostate Cancer

Xanthogranulomatous prostatitis (XGP) is a rare chronic inflammatory condition of the prostate that can clinically and radiologically mimic prostate cancer (PCa). We present a case of XGP in an elderly male with markedly elevated prostate-specific antigen (PSA) levels and imaging findings suggestive of locally advanced PCa. A 66-year-old male with a two-month history of intermittent fever was incidentally found to have two vesical calculi (13 mm and 9 mm) and grade 3 prostatomegaly (57 cc) with a large median lobe. He reported no lower urinary tract symptoms (LUTS). The patient underwent elective cystolithotripsy but developed hematuria, necessitating cystoscopic fulguration of the bladder neck. Postoperatively, his serum PSA was 100 ng/mL. Multiparametric MRI (mpMRI) revealed a Prostate Imaging Reporting and Data System (PIRADS) 5 lesion in the left transition zone with extraprostatic extension (stage T3b) and a PIRADS 2 lesion in the right peripheral zone. Ga-68 positron emission tomography with prostate-specific membrane antigen (PSMA PET-CT) demonstrated low-grade heterogeneous PSMA uptake (SUVmax 3.9) in the prostate. A transrectal ultrasound (TRUS)-guided prostate biopsy showed benign prostatic hyperplasia (BPH) with prostatitis. Following a failed voiding trial and recatheterization, the patient underwent transurethral resection of the prostate (TURP), which was uneventful. Histopathology revealed XGP with BPH. The patient had a successful postoperative recovery with effective voiding. XGP is an uncommon condition that can present with markedly elevated PSA and imaging findings suggestive of advanced PCa. This case underscores the importance of correlating histopathological findings with clinical and imaging data to avoid overtreatment.