Since Brucellosis is not an endemic disease in the Marmara Region of Turkey, presentation of the disease as Brucella epididymo-orchitis is not a common finding. The seropositivity rate in the healthy population in all geographical regions of Turkey is between 2-6%.
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Although epididymo-orchitis is the most common genitourinary involvement of Brucellosis, it is rarely the leading finding in most of the cases. In fact our patient didn’t present with typical findings of Brucellosis like muscle ache (myalgia), joint ache (arthralgia), gastrointestinal system symptoms such as nausea, vomiting, abdominal pain, constipation and rarely anemia, leucopenia, thrombocytopenia, localized and generalized lymphadenopathy, dermatological findings like maculopapular rash and neurological findings like meningitis, encephalitis and cardiac involvement like endocarditis and pulmonary involvement.
Hospitalization was indicated for our epididymo-orchitis patient who was suffering from fever-related fatigue with left testicular swelling and tenderness. Typical undulant fever pattern for Brucellosis was not observed in our patient but his fever was always present between 39-40 Cº. Testicular swelling can either be acute or chronic and it can be either unilateral as in our patient or bilateral in some of the cases5-13. As testicular swelling and fever are the leading features of almost every classical epididymo-orchitis case, the only key that made us suspect Brucella orchitis was resistant ongoing fever for 96 hours after 2 different antibiotic treatments. Wright agglutination test and blood culture were used in differential diagnosis to exclude other causes of epididymo-orchitis. The Brucella Wright titer was found to be 1/160 and Brucella sp was isolated in blood culture confirming the diagnosis of Brucella epididymo-orchitis. Urine culture and microscopy were negative as it is in almost 65 % of all Brucella epididymo-orchitis cases14.
In the literature, the incidence of epididymo-orchitis for Brucellosis in Turkey was noted between 2-12.7%7-9. Human brucellosis incidences cases in some Mediterranean countries are high, such as Greece and Spain where the true incidence for Brucella epididymo-orchitis is meant to be %12 and %2-20 respectively10-11. In another study from Saudi Arabia the incidence was noted as 1.6%12.
Differential diagnosis should include tumor, trauma, hematoma, cyst, torsion and other acute or chronic infections (abscess, gonorrhea, tuberculosis, mumps, syphilis, Chlamydia) which may lead to acute testicular swelling5. Beside clinical findings and physical examination, scrotal USG and testicular scintigraphy can also be used in differential diagnosis15. Scrotal USG findings in our case included parenchymal heterogeneity, pyocele and hydrocele formations but none of these particular findings helped us in differentiating the lesion from normal epididymo-orchitis. Pathological examination of Brucella epididymo-orchitis reveals a granulomatous inflammatory reaction and focal necrotizing areas. Most of these patients are reported to have a low fertility potential in the follow-up period8.
An interesting aspect of a study done by Akıncı et al showed clinical unilateral infection of the testis (brucella epididymo-orchitis) resulting in aspermia and oligospermia8. So they hypothesized that brucellosis causes decreased sperm counts and possibly caused infertility. Two possible explanations for these results were referred to Osegbe who found similar results in patients with unilateral epididymoorchitis and performed bilateral testicular biopsies and to Ingerslev et al. who found a causal link between acute epididymitis and the development of antisperm antibodies16-17.
Antimicrobial therapy is generally enough in Brucellosis with uncomplicated epididymo-orchitis18. In antimicrobial therapy most common combinations are rifampicin plus either tetracycline, doxycycline or ofloxacin, and doxycycline plus streptomycin5,18-20. There are several articles about the treatment efficiency of these combination therapies in the literature and the efficiency of each combination seems to be similar. The treatment period for the rifampicin plus doxycycline combination should be at least 6 weeks. The disease may relapse in some patients. In a report from Spain, the incidence of relapse was 25 %11. Patients with necrotizing orchitis who can’t benefit form antibiotic therapy may need orchiectomy5,13, and 21
In conclusion, Brucella epididymo-orchitis should be kept in mind for the etiology of epididymo-orchitis resistant to standard therapeutic approach especially in our country where Brucellosis is endemic in some regions.
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