Infections caused by organisms of the genus Brucella can produce orchitis in susceptible mammals, including humans [4
]. Brucellosis is a relatively common cause of BEO in some geographic areas, including Iran, where Brucella melitensis is endemic. Only a few case series from Iran that discuss Brucella epididymoorchitis have been published. Rates of epididymoorchitis in cases of human brucellosis have ranged from 2-20% in various reports [2
In the current study, epididymoorchitis occurred in 6.70% of all patients and 11.11% of male patients with brucellosis in a 13 year period. In a previous study of 96 patients with epididymoorchitis in Imam Khomeini hospital (1995-1996) BEO was found in 14.6% of cases. Navarro reported BEO in 6% of patients in his study (1988) in Spain [10
], but in Guindu-Sevillano's study, 12.8% of cases of epididymoorchitis in Spain were due to Brucella infection [13
]. Memish et al. reported BEO in 1.6% of their patients with brucellosis [7
]. A seven year study in Turkey (Yurdakal et al.) revealed BEO in 17% of all cases with epididymoorchitis[11
]. The rate of epididymoorchitis in our patients was similar to that reported from other studies in endemic areas.
The diagnosis of scrotal disease was based on clinical findings and laboratory data. BEO can be distinguished from other acute nonspecific types of orchitis by various clues, including: gradual onset and longer duration, positive contact history with animals or unpasteurized dairy products, typical undulant fever, and abnormal urologic findings. In most of our patients, as in other studies, fever, scrotal pain and swelling were found, but signs and symptoms of urinary infection were observed in 30% of patients.
In a previous study in Sari Imam Khomeini hospital, signs and symptoms of lower urinary tract infection were found in 28% of patients [12
]. In contrast, signs of urinary tract infection were observed in 7% of cases in Spain [9
] and 19.2% in Saudi Arabia [5
]. Khan et al, [14
] found lower urinary tract symptoms in 69% of patients, but the other authors describe a characteristic absence of these symptoms in patients with BEO [5
]. According to the different reports of the signs and symptoms of urinary tract infection, we cannot use this finding as a diagnostic criterion for BEO. We must consider BEO in every patient with scrotal swelling and fever, without paying any particular attention to urinary symptoms. The hematological findings are usually non specific and cannot help with the diagnosis of BEO. These disturbances are usually mild. A low level of hemoglobin may be the result of prolonged infection and a moderate elevation in ESR is found in most cases. Most reports describe no changes in urinary sediment, but in our study we noticed a change in two patients, who showed hematuria and pyuria, similar to some patients in the Spanish study [10
]. Liver function tests disclosed a mild to moderate increase in the serum level of hepatic transaminase. These abnormalities in liver function tests may be caused by granulomatous Brucella hepatitis, However, when serious liver malfunction is found, intercurrent disease must always be excluded [5
]. In our series, 16.7% of patients had mild elevation in liver function tests.
The diagnosis of brucellosis was made by isolation of Brucella species from blood cultures or epididymal aspirates, or by standard tube agglutination tests, revealing a titer of antibodies to Brucella antigen of ≥ 1:160, in addition to compatible clinical findings [5
]. Standard urine culture is inadequate for the diagnosis of genitourinary brucellosis.
The presumptive diagnosis of Brucella orchitis can be made by serological testing [4
]. Positive results (titers of antibodies to Brucella species of > 1:160 with the standard tube agglutination test) are common. However, low titers determined by the standard tube agglutination test have been reported, and rarely, some patients with brucellosis have positive blood cultures but negative serological results [4
In our study, all of the patients had standard tube agglutination titers ≥ 1:160 and those of 2ME > 1:80. Ultrasonography plays an important role in the diagnosis, assessment and management of patients with BEO [4
]. Ultrasonography is more useful in excluding the possibility of abscess or tumor than in helping to establish the primary clinical diagnosis [4
]. The most notable ultrasonographic finding was an enlarged and heterogeneous epididymis, predominantly the body and tail. Testicular involvement consisted of a diffusely hypoechoic testis or focal intratesticular areas. Thickening of the scrotal wall and tunica albuginea, and moderate hydrocele were also noted occasionally [4
]. Unilateral epididymoorchitis is the most common genitourinary complication of brucellosis. Infection limited to the testis is rare; the epididymis is usually involved in patients who have acute inflammation [4
]. In the normal epididymis, very few or no vessels are seen on color Doppler sonogram, but the size and number of vessels increase if the epididymis is inflamed. The changes seen in color Doppler images occur sooner than the changes evident on a sonogram [4
In our series, 86.4% of patients had unilateral testicular involvement. All of our cases had testicular involvement, and in 40.1% this was accompanied by epididymal involvement. In the study that was conducted in Spain, 91% of patients had unilateral involvement. Epididymitis was found in 41.1% of the cases and changes in echotextures of the testis were detected in 82% of sonograms. The lower number of patients with epididymal involvement reported in our series could be a result of the lack of use of color Doppler sonograms for diagnosis.
The existence of a hypoechoic lesion in the testis sonogram is a sign of testicular abscess formation, and surgery is usually needed in these cases [4
]. In our study, abscess formation was observed in five patients (16.7%), of which two cases responded to medical treatment. Drainage of the abscess was performed for two cases and orchiectomy in the other.
In a study conducted in Spain, 81% of the patients underwent surgery [5
]. In the other studies reviewed the need for surgery was lower. The relatively high frequency of surgery in our patients was probably a result of the fact that the urology center in Imam Komeini hospital is a referral site. Necrotizing orchitis is a rare form of Brucella infection, which must be distinguished from necrotizing involvement arising from other pathogens (eg. Mycobacterium tuberculosis, Salmonella species) [4
]. In addition, some acute cases may be mistaken for urinary tract infections with Gram-negative pathogens [4
]. In brucellosis endemic areas, clinicians who encounter epididymoorchitis should consider the likelihood of brucellosis. A careful history, a meticulous physical examination and a rapid laboratory evaluation will assist the diagnosis. Clinical and serological data are sufficient for diagnosis. Conservative management with a combination of antibiotics is adequate for the management of most cases of Brucella epididymoorchitis.