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A Complication of Brucellosis: Epididymoorchitis

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A Complication of Brucellosis: Epididymoorchitis View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by Elsevier - Publisher Connector International Journal of Infectious Diseases (2006) 10, 171—177 http://intl.elsevierhealth.com/journals/ijid A complication of brucellosis: Epididymoorchitis Esragu¨l Akıncı a,*,Hu¨rrem Bodur a, Mustafa Aydın C¸evik a, Ays¸e Erbay a, Selim Sırrı Eren a,I˙pek Zıraman b, Neriman Balaban c, Ali Atan d,Gu¨lu¨s¸an Ergu¨l e a Department of Infectious Diseases and Clinical Microbiology, Ankara Numune Education and Research Hospital, Ankara, Turkey b Department of Radiology, Ankara Numune Education and Research Hospital, Ankara, Turkey c Department of Microbiology, Ankara Numune Education and Research Hospital, Ankara, Turkey d Department of Urology, Ankara Numune Education and Research Hospital, Ankara, Turkey e Department of Pathology, Ankara Numune Education and Research Hospital, Ankara, Turkey Received 18 October 2004; received in revised form 28 January 2005; accepted 24 February 2005 Corresponding Editor: Marguerite Neill, Pawtucket, USA KEYWORDS Summary Brucellosis; Brucella mellitensis; Background: Epididymoorchitis is the most frequent genitourinary complication of Brucella abortus; brucellosis. Epididymoorchitis; Methods: This prospective study was conducted between February 2001 and January Genitourinary 2004, prospectively. Male patients diagnosed with brucellosis were included in this infections study and evaluated for testicular involvement. Results: Epididymoorchitis was detected in 17 out of 134 (12.7%) male patients with brucellosis. Mean age of the patients was 36.9 Æ 7.1 years. Twelve patients (70.6%) had acute, four patients (23.5%) had subacute, and one patient (5.9%) had chronic brucellosis. The most common symptoms were scrotal pain (94%) and swelling (82%). Elevenpatientshadunilateralepididymoorchitis,fourhadunilateralorchitisandtwohad unilateral epididymitis. A testicular abscess was detected in one patient. Sperm analysis was performed on 14 patients. Five patients had aspermia and eight had oligospermia. Combined antibiotic therapy was started and continued for 6—8 weeks. Orchiectomy was required for two patients and granulomatous orchitis was detected in the resected specimens. Relapse occurred in only one patient. Three patients had permanent oligos- permia and one patient had permanent aspermia after the antibiotic therapy. Younger age, high C-reactive protein level and blood culture positivity were statistically sig- nificant differences between the patients with and without epididymoorchitis. * Corresponding author. Present address: Department of Infectious Diseases and Clinical Microbiolgy, Numune Education and Research Hospital, C¸igdem Mahallesi, Segmen Sitesi, A Blok, No: 15, 06530 Karakusunlar, Ankara, Turkey. Tel.: +90 3122878183. E-mail address: [email protected] (E. Akıncı). 1201-9712/$32.00 # 2005 International Society for Infectious Diseases. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.ijid.2005.02.006 172 E. Akıncı et al. Conclusions: Brucellosis should be considered in the diagnosis of scrotal diseases in endemic areas. A conservative approach is usually adequate for managing brucellar epididymoorchitis. However, infertility problems may develop in these patients. Well- designed further investigations are needed to explain the relationship between bru- cellar epididymoorchitis and infertility in man. # 2005 International Society for Infectious Diseases. Published by Elsevier Ltd. All rights reserved. Introduction tenderness) and ultrasonographic examination. Mumps, testicular malignancies and other bacterial Brucellosis is a systemic infection in which any organ infections were excluded by: absence of history of orsystemofthebodycanbeinvolved.1 Inmen,various parotitis, genitourinary tract disease, genitourinary genitourinary infections including epididymoorchitis, tract manipulation, urethral discharge, and sexual prostatitis, testicular abscess and seminal vesiculitis exposure; negative mumps IgM with ELISA test; have been attributed to brucellosis.2 The most fre- normal serum amylase, alpha-fetoprotein and quent genitourinary complication of brucellosis is beta-human chorionic gonadotropin levels and epididymoorchitis. It was first described by Hardy negative scrotal ultrasonographic findings compati- as a cause of granulomatous orchitis in 1928.3 ble with testis tumor. Brucellosis is an endemic disease in Turkey. The Demographic data, clinical and laboratory seropositivity rate is 1.8% in the healthy population.4 findings, treatment, outcome and follow-up of Itisfrequentespeciallyintheruralareasofthemiddle the patients were recorded. The patients with and southeastern regions and Brucella melitensis is epididymoorchitis were followed up at least six the most prevalent strain.5—8 In this study, clinical months after the completion of the antibiotic characteristics and outcomes of 17 patients with therapy by clinical, laboratory and ultrasono- brucellar epididymoorchitis are presented and com- graphic findings. Outcomes were classified as fail- pared with male patients without epididymoorchitis. ure, relapse or cure. Relapse was defined as reappearance of signs and symptoms within six months after the completion of antibiotic therapy. Patients and methods Sperm analysis was also done before and after treatment to evaluate the effect of the infection The hospital setting and study population on fertility. Due to financial and other reasons, scrotal ultrasonography and sperm analysis could Ankara Numune Education and Research Hospital is a not be performed on the patients without epidi- 1100-bed referral and tertiary-care hospital in Tur- diymoorchitis. key. This study was conducted in the Infectious Dis- eases and Clinical Microbiology Clinic between Ultrasonographic examination and February 2001 and January 2004, prospectively. Male technique patients diagnosed with brucellosis were included in this study and evaluated for testicular involvement. On admission, all of the patients with epididymoor- chitis underwent bilateral scrotal ultrasonography. In nine of them, the vascularity of the testis was Clinical assessment and definitions evaluated by color Doppler ultrasonography. Control scrotal ultrasonographic examination after the com- Definitive diagnosis of brucellosis was made by iso- pletion of the treatment was planned for all patients lation of Brucella species from the blood cultures. In with epididymoorchitis but it could be done in only the absence of positive blood culture, presumptive eight patients. diagnosis was made serologically by positive serum The sonographic studies, including gray-scale standard tube agglutination test (SAT) together with ultrasonography and color Doppler and power Dop- compatible clinical signs and symptoms of brucel- pler examinations, were performed by the same losis.1 According to the duration of symptoms, physician with a General Electric Logic-9 System patients were classified as having acute (<2 (GE Medical Systems, Solingen, Germany) using 5— months), subacute (2—12 months) or chronic bru- 14 mHz linear array transducer.The examination was cellosis (>12 months).9 Among these patients with performed with the patients in a supine position. brucellosis, the diagnosis of epididymoorchitis was Serial transverse and sagittal images of each testis based on clinical findings (scrotal swelling, pain or and epididymis were obtained in addition to at least A complication of brucellosis 173 one image showing both testes for direct compar- 7.0 (College Station, TX) was used for the statistical ison and the following parameters were assessed: analysis. epididymal echogenicity; testicular echogenicity and size; presence and characteristics of hydro- cele. For color Doppler and power Doppler exam- Results ination, while the clinically inflamed testis was studied, the machine settings were adjusted to Between February 2001 and January 2004, a total of optimize the detection of blood flow. We evaluated 134 male patients with brucellosis were followed up. the scrotum of each patient by subjective side-by- The diagnosis was bacteriologically confirmed in 45 side comparison; abnormal blood flow was defined patients. In the remaining 89 patients, serological as a subjective increase or decrease in number, diagnoses were made. Of these 134 male patients, 17 size or length of visible vessels in the affected (12.7%) had brucellar epididymoorchitis. Mean age of testis compared with the unaffected testis. the patients with epididymoorchitis was 36.9 Æ 7.1 (range 23—45) years. Fifteen (88.2%) were married Microbiologic studies and had children. A total of 11 patients (64.7%) lived in rural areas; 13 patients (76.5%) were breeding Blood samples were cultured by use of an automated cattle and 15 patients (88.2%) had consumed unpas- culture system (Organon Tecnica BacT/Alert Bio- teurized dairy products. Occupational exposure was Merieux, France). Biotyping of the strains was car- detected in two patients (11.8%) who were working in ried out at the reference laboratory (Pendik the microbiology laboratory. Veterinary Research Laboratory, Istanbul, Turkey). At admission, duration of epididymoorchitis was a Standard tube agglutination tests and Coombs tests mean 11.8 Æ 12 (range 1—40) days. Twelve patients were performed. An agglutination titer of 1/160 (70.6%) had acute, four patients (23.5%) had suba- was accepted as positive.1,4,10 cute and one patient (5.9%) had chronic brucellosis. In one patient, brucellar epididymoorchitis Statistical
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