Endemic brucellar epididymo-orchitis: a 10-year experience

Brucella epididymo-orchitis: A single-center experience with a review of the literature

Brucella epididymo-orchitis (BEO) is a rare complication of brucellosis. Despite the high incidence of brucellosis in developing countries, few case series on BEO are available. This study focuses on the clinical presentations, diagnosis, and treatment of BEO with a review of the literature. This study included consecutive BEO patients diagnosed and treated at Smart Health Tower between 2021 and 2023. The required data were retrospectively collected from patients' profiles. The BEO diagnosis was established through scrotal Doppler ultrasound in cases with a positive Rose Bengal test and positive IgG and IgM results for brucellosis, in addition to scrotal pain and swelling. This study included 11 cases whose ages ranged from 22 to 55 years. Most of the cases presented with testicular pain (72.7%), followed by fever (63.6%) and arthralgia (63.6%). The right side (54.5%) was slightly more affected than the left side (45.5%). The major abnormal laboratory finding was an elevated C-reactive protein (82%). The treatment was conservative, in which a combination of gentamicin, doxycycline, and rifampicin was administered to the patients for about 6-8 weeks. One case underwent an orchiectomy due to the abscess formation. All the patients responded well to the treatment, with no recurrence. In the Middle East, brucellosis remains a concerning infectious disease. Early diagnosis, aimed at preventing abscess formation and other complications, takes first priority to avoid invasive interventions.

Early predictors of Brucella epididymo-orchitis

Introduction

Epididymo-orchitis (EO) is a common urological condition. In endemic areas, EO may be the presenting picture of brucellosis. Early suspicion and proper diagnosis is necessary for patient recovery.

Objective

The aim of our study is to identify early predictors of Brucella EO.

Patients and Methods

We retrospectively collected the data of all patients who were treated at the Urology Unit, Farwaniya Hospital, with acute EO above the age of 12 years between April 2017 and February 2019. Data from electronic and hardcopy files were gathered and analyzed. The diagnosis of acute EO was based on clinical, laboratory, and radiological findings. A total of 120 patients under the diagnosis of EO, epididymitis, and orchitis were reviewed. Thirty-one patients were tested for Brucella based on the history of animal contact, ingestion of unpasteurized dairy products, or persistent fever for more than 48 h. of those patients, 11 tested positive for Brucella orchitis.

Results

A comparison between Brucella-positive and Brucella-negative patients regarding age, presence of fever, complete blood count (CBC) parameters, pyuria, and abscess formation was made. In the Brucella group, 72% of the patients had a history of animal contact compared to 33% in non-Brucella group (P = 0.006). When comparing CBC parameters in the two groups, Brucella group had statistically significant lower total leukocytic count and neutrophil count (mean ± standard deviation [SD]) 13.07 ± 4.22, 6.4 ± 9.98 versus Brucella negative group 17.35 ± 5.28, 7.8 ± 10.53, and P values were 0.037 and 0.004, respectively. Brucella group showed lymphocytosis (mean ± SD) 25.95 ± 9.78 versus non-Brucella group 13.22 ± 8.05 and P < 0.01.

Conclusion

Brucella orchitis constituted 9% of the orchitis patients treated in our hospital. Patients with a history of animal contact, EO with lymphocytosis, and relative neutropenia should raise the suspicion for Brucella orchitis in endemic areas.

Brucellar epididymo-orchitis: Symptoms, diagnosis, treatment and follow-up of 50 patients in Iran

Introduction

Epididymo-orchitis (EO) is a disease of both the epididymis and ipsilateral testis. Brucellar epididymo-orchitis (BEO) is an uncommon localized infection of the testis and epididymis which occurs in about 2-14 % of all patients with brucellosis as a result of urine Brucella removal or due to blood-borne septic metastasis.

Methods

Between January 2018 and June 2021, 50 patients with fever, chills, swelling, and pain of the testicle (testicles) were referred to our center. Two approaches were used for the treatment of brucellarepididymo-orchitis among these individuals. Intravenous Gentamicin and Doxycycline were used in seven cases, while Rifampicin was added to this combination for the remaining 43 patients. Intravenous Gentamicin was administered for 7 days and the other drugs were used for 45 days. All patients were followed up for six months by monitoring the symptoms and signs of the disease.

Results

None of the patients had been diagnosed with brucellosis before referral to our clinic. 43 patients were successfully treated by. Intravenous Gentamicin, Doxycycline and Rifampicin, whereas seven patients were fully treated using. Intravenous Gentamicin and Doxycycline. The two therapeutic groups were hospitalized for 7.56 ± 3.45 (3-23) and 10.14 ± 1.77 (8-13) days, respectively. Treatment failure, drug side effects, and disease complications were not observed in any of the cases over a 6-month follow-up period.

Conclusions

Physicians should be alert regarding Brucellarepididymo-orchitis (BEO) within the differential diagnosis of nonspecific epididymo-orchitis, especially in regions where the disease is endemic. Delay in diagnosis or inappropriate management of BEO may result in complications.

Pathogenesis of Brucella epididymoorchitis-game of Brucella death

Brucellosis is a worldwide zoonotic disease caused by Brucella spp. Human infection often results from direct contact with tissues from infected animals or by consumption of undercooked meat and unpasteurised dairy products, causing serious economic losses and public health problems. The male genitourinary system is a common involved system in patients with brucellosis. Among them, unilateral orchitis and epididymitis are the most common. Although the clinical and imaging aspect of orchi-epididymitis caused by brucellosis have been widely described, the cellular and molecular mechanisms involved in the damage and the immune response in testis and epididymis have not been fully elucidated. In this review, we first summarised the clinical characteristics of Brucella epididymo-orchitis and the composition of testicular and epididymal immune system. Secondly, with regard to the mechanism of Brucella epididymoorchitis, we mainly discussed the process of Brucella invading testis and epididymis in temporal and spatial order, including i) Brucella evades innate immune recognition of testicular PRRs；ii) Brucella overcomes the immune storm triggered by the invasion of testis through bacterial lipoproteins and virulence factors, and changes the secretion mode of cytokines; iii) Brucella breaks through the blood-testis barrier with the help of macrophages, and inflammatory cytokines promote the oxidative stress of Sertoli cells, damaging the integrity of BTB; iv) Brucella inhibits apoptosis of testicular phagocytes. Finally, we revealed the structure and sequence of testis invaded by Brucella at the tissue level. This review will enable us to better understand the pathogenesis of orchi-epididymitis caused by brucellosis and shed light on the development of new treatment strategies for the treatment of brucellosis and the prevention of transition to chronic form. Facing the testicle with immunity privilege, Brucella is like Bruce Lee in the movie Game of Death, winning is survival while losing is death.HIGHLIGHTSWe summarized the clinical features and pathological changes of Brucellaepididymoorchitis.Our research reveals the pathogenesis of Brucella epididymoorchitis, which mainly includes the subversion of testicular immune privilege by Brucella and a series of destructive reactions derived from it.As a basic framework and valuable resource, this study can promote the exploration of the pathogenesis of Brucella and provide reference for determining new therapeutic targets for brucellosis in the future.

Genital Brucella suis Biovar 2 Infection of Wild Boar (Sus scrofa) Hunted in Tuscany (Italy)

Brucellosis is a zoonosis caused by different Brucella species. Wild boar (Sus scrofa) could be infected by some species and represents an important reservoir, especially for B. suis biovar 2. This study aimed to investigate the prevalence of Brucella spp. by serological and molecular assays in wild boar hunted in Tuscany (Italy) during two hunting seasons. From 287 animals, sera, lymph nodes, livers, spleens, and reproductive system organs were collected. Within sera, 16 (5.74%) were positive to both rose bengal test (RBT) and complement fixation test (CFT), with titres ranging from 1:4 to 1:16 (corresponding to 20 and 80 ICFTU/mL, respectively). Brucella spp. DNA was detected in four lymph nodes (1.40%), five epididymides (1.74%), and one fetus pool (2.22%). All positive PCR samples belonged to Brucella suis biovar 2. The results of this investigation confirmed that wild boar represents a host for B.suis biovar. 2 and plays an important role in the epidemiology of brucellosis in central Italy. Additionally, epididymis localization confirms the possible venereal transmission.

Epididymitis associated with bacteremic pneumococcal pneumonia

We describe a case of a 56 year-old male who presented to the hospital with pneumonia and bacteremia secondary to Streptococcus pneumoniae. After admission and initiation of appropriate antibacterial therapy he began to complain of scrotal pain. Ultrasound of the testes confirmed findings of left-sided epididymitis. Urine culture, urine gonorrhea and chlamydia nucleic acid amplification and HIV testing were negative. Clinical picture suggested seeding of the epididymis with Streptococcus pneumoniae and resulting infection.

Urological infections in the developing world: an increasing problem in developed countries

PURPOSE

Infectious diseases that often follow geographical distribution patterns are increasingly crossing such boundaries, aided by human travel and commerce. These pose a new challenge to physicians who are required to diagnose previously unseen conditions and address drug-resistant organisms. We review some such common infections.

METHODS

A literature review was performed for six common urological infections and a narrative review based on recent publications on these infections was compiled.

RESULTS

In Urology, some infections that are now crossing geographical boundaries include Brucellosis, Schistosomiasis, Tuberculosis, Filariasis, Hydatidosis and emphysematous pyelonephritis. Brucellosis, a zoonotic infection, is common in the Mediterranean areas, Asia, South America and Africa. Infection can involve all parts of the genitourinary tract. Schistosomiasis, a parasitic disease, is particularly common in Sub-Saharan Africa and may have bacterial superinfection. Voiding symptoms are common and bladder carcinoma may develop. Tuberculosis affects almost every organ in the body and in the male genital system, often presents with abscesses, nodules, ulcers and infertility that is difficult to manage. Filariasis is caused by two species of worms and is transmitted through a bite from a mosquito carrying larvae of the worm. It causes lymphatic obstruction leading to scrotal edema, hydrocoele to elephantiasis of scrotum. Emphysematous pyelonephritis is a life-threatening suppurative necrotizing infection of the renal parenchyma. While not being geographically limited, it is more common in developing areas with poor health care access. Genitourinary hydatidosis is a rare disease that is associated mainly with renal involvement in the genitourinary tract. Large cysts with destruction of renal parenchyma may be found.

CONCLUSIONS

Although uncommon, these urological infections are associated with significant morbidity and mortality and awareness in all healthcare settings is now an essential requirement.

Acute epididymo-orchitis from brucellosis melitensis in Australia

Brucellosis epididymo-orchitis (BEO) is extremely rare in non-endemic areas such as Australia. While epididymo-orchitis is relatively common in adolescent men, when presented with a significant travel history, consideration should be given to rare causes such as this. Here, we present a case of BEO in a young 18-year-old man who recently migrated from Greece, with symptoms of acute scrotal pain, swelling and persistent fever. Brucella melitensis was isolated in the blood culture and confirmed with PCR. We suspect transmission was related to ingestion of unpasteurised goat dairy products. He made a full recovery after 7 days of intravenous gentamicin and 6 weeks of oral doxycycline. BEO should be considered in those who present with acute scrotal pain and fever after a recent history of travel to or from a brucellosis- endemic area.

Immuno-pathophysiological responses of mouse model to experimental infection with Brucella melitensis and its lipopolysaccharides via intraperitoneal route

Brucella melitensis is one of the major zoonotic pathogens with significant economic implications worldwide. The pathogenicity is complex and not always well understood. Lipopolysaccharide (LPS) remains the major virulent factor of B. melitensis and responsible for the mechanism by which the pathogen causes its deleterious effects. In this study, 84 mice of 6-8 weeks old of both sexes were divided equally into 3 groups; namely Brucella melitensis infected group, lipopolysaccharide (LPS) infected group and control group. The former two groups contained 36 mice each with equal gender distribution. The control group consisted of 12 mice only. Animals in B. melitensis infected group, a single inoculum of 0.4 ml containing 10⁹ of B. melitensis were intraperitoneally challenged while animals in LPS group, a single dose of 0.4 ml containing LPS extracted from the B. melitensis were intraperitoneally inoculated. Animals in control group received intraperitoneally, a single dose of 0.4 ml phosphate buffered saline (PBS) of pH7. Animals that were infected intraperitoneally with B. melitensis demonstrated significant clinical presentation; gross and histo-pathological evidence than LPS infected group. However, both infected groups showed elevated levels of interleukins (IL-1β and IL6), antibody levels (IgM an IgG) as early as 3 days post-infection with predominance in LPS infected group. In contrast, low levels of sex related hormonal changes in which LPS infected group showed the least concentration were also detected throughout the experimental period. In conclusion, B. melitensis can be transmitted via gastrointestinal, respiratory and reproductive tract. Moreover, LPS stimulated significantly the innate and acquired immune system without significant systemic dysfunction, suggesting potentiality of the protective properties of this component as alternative vaccine for brucellosis infection.

Testicular infection in brucellosis: Report of 34 cases

BACKGROUND/PURPOSE

To present clinical and laboratory features, treatment options, and outcome in patients with brucellar testicular infection and to compare them with analogous in brucellar patients without testicular involvement.

METHODS

Thirty four brucellar patients with testicular infection treated in two general hospitals in the Republic of Macedonia, during the period 1998-2009, were retrospectively analyzed. Their clinical and laboratory characteristics were compared with analogous in 364 male brucellar patients without testicular infection, who were treated at the same hospitals during the same time period.

RESULTS

Brucellar testicular infection was evident in 34 (8.5%) out of 398 male patients with brucellosis. The median age of the patients was 46.5 years. In all patients testicular involvement was presented as an acute form with a median duration of 5 days (range, 2-14 days) prior to diagnosis. Twenty-three of the patients had at least one other simultaneous focal infection. After starting with the treatment testicular infection lasted a median 10 days, range 7-21 days. Brucellar patients with testicular infection when compared with other brucellar patients more frequently manifested fever (97% vs. 61%), concomitant spondylitis (32% vs. 16%), and urinary system involvement (12% vs. 2%). Also, the relapse rate in patients with testicular involvement was significantly higher (24% vs. 9%).

CONCLUSION

In endemic regions brucellosis should be taken into consideration in any patient with testicular infection. Brucellar testicular involvement is usually characterized with a severe acute clinical presentation and a high percentage of relapses which entails the need of timely recognition and proper treatment duration of at least 60 days.

[Inflammatory diseases of scrotal organs in patients with brucellosis: Improvement of therapy]

AIM

To evaluate the efficacy of cycloferon used in the combination treatment of scrotal inflammatory diseases (SID) in patients with brucellosis.

SUBJECTS AND METHODS

A total of 150 male patients with chronic brucellosis (CB) were examined. Inquiry, questioning, physical and ultrasound examinations, and spermiogram analysis were used to detect of diseases of the reproductive system. Twenty-two CB patients with SID were examined over time (before and after cycle therapy). In Group 1, combination therapy included 2 cycles of five intramuscular injections of cycloferon 0.25 g in each at a 10-day interval. In Group 2, a package of therapeutic measures meets the generally accepted standards. and Incorporation of cycloferon into the combination therapy of SID patients with CB positively affected the time course of clinical changes and spermatogenesis, declines the number of SID exacerbations, improved quality of life, and failed to cause side effects.

CONCLUSION

The findings allow us to recommend cycloferon as the drug of choice in treating CB patients with SID.

Prevalence of Brucella antibodies on a previously acute brucellosis infected population: sensitivity, specificity and predictive values of Rose Bengal and Wright standard tube agglutination tests

PURPOSE

Brucellosis is a zoonosis with worldwide distribution. The presence of antibodies after acute infection and the prevalence of positive serology in endemic area are not well documented.

METHODS

Patients hospitalized with acute brucellosis were relocated 3-13 years after the initial infection. Hospital records of the initial infection were retrieved, and examination of Brucella antibodies using Rose Bengal test (RBT) and Wright standard tube agglutination (STA) test was performed.

RESULTS

Eighty-three patients were hospitalized from 2000 to 2010; 50.6 % were farmers and 37.4 % livestock farmers. All had febrile illness and various focal complications. All had positive serology, and 82.2 % had positive blood cultures; 91.5 % were treated with streptomycin plus doxycycline. Seventy-two (86.7 %) were relocated on follow-up. Nine (12.5 %) had positive RBT and STA up to 1/320. Occupational history was associated with positive serology (p = 0.0172), and 8/9 of the positive individuals were livestock farmers (38.0 % of the livestock farmers checked). Residence, years after the infection, clinical presentation of brucellosis and treatment were not associated with serology results. Both tests had excellent sensitivity (nearly 100 %), specificity 87.5 % and excellent negative predictive value (nearly 100 %); however, positive predictive value was only 11.4 %.

CONCLUSIONS

Rapid and low-cost tests as RBT and STA are still very useful in diagnosing acute brucellosis; however, every positive test must be examined together with clinical symptoms and occupational history. The tests can be used as screening tests in endemic populations to rule out acute brucellosis.

First report of orchitis in man caused by Brucella abortus biovar 1 in Ecuador

We present a 44-year-old man from a rural community in northern Ecuador who worked on a cattle farm where he was involved with primary veterinary care, including assistance during births (or calving) and placenta retention and artificial insemination, with minimal precautions. In September of 2009, quite abruptly, he developed asthenia and hypersomnia without any apparent cause or symptoms like fever, chills, or night sweats. On November 14, 2009, he suffered from pain and edema in the right testicle that coincided with pain in the abdomen. Clinical, serological, and bacteriological investigations confirmed the first case of unilateral orchitis in man in Ecuador caused by Brucella abortus biovar 1. Because brucellosis is a neglected disease, special attention should be given to it in the training of medical and veterinary students.

Clinical findings, diagnostic approach, and outcome of Brucella melitensis epididymo-orchitis

We have studied 912 patients with brucellosis. Of these, 631 (69.2%) were male and 48 had epididymo-orchitis, giving an incidence of epididymo-orchitis of 7.6%. The duration of symptoms before diagnosis was 52.5 +/- 70 days. All the patients had fever, swelling, and scrotal pain, but only 2 (4.2%) reported urinary symptoms. Seven patients (14.5%) had leukocyte figures above 11 x 10(9)/L, and urine analysis was normal in 69% of the patients. Blood cultures were positive in 65.8% of cases. A total of 33 patients (68.8%) received a combination of doxycycline plus streptomycin and 13 (27.1%) doxycycline plus rifampin. The overall percentage of failure or relapse was 8.8%: 7.1% in the doxycycline plus streptomycin group and 20% in the doxycycline plus rifampin group. None of the patients required surgery. Pending clinical trials to confirm the results, conservative management with a combination of doxycycline for 2 months and streptomycin for 14 to 21 days appears to be adequate and could avoid unnecessary orchiectomy.

Rapid Diagnosis of Brucella Epididymo-Orchitis by Real-Time Polymerase Chain Reaction Assay in Urine Samples

PURPOSE

We studied the diagnostic yield of a real-time polymerase chain reaction assay in urine samples for the rapid diagnosis of brucella epididymo-orchitis compared to that of conventional microbiological techniques.

MATERIALS AND METHODS

We used an SYBR Green I LightCycler based real-time polymerase chain reaction to retrospectively study 10 urine samples from patients with Brucella epididymo-orchitis. The assay amplifies a 223 bp sequence of a gene that codes for the synthesis of an immunogenetic membrane protein specific for Brucella genus (BCSP31). After amplifying this 223 bp sequence we performed melting curve analysis to verify the specificity of polymerase chain reaction products.

RESULTS

Brucella melitensis was isolated from blood cultures in 9 cases (90%). Wright's seroagglutination was negative or inconclusive in 30% of cases. Brucella was isolated from urine in only 1 case, whereas real-time polymerase chain reaction assay in urine was positive in 9 (90%). Also, results were available in 4 hours, whereas mean time to availability of the final blood culture results was 5.8 days (range 4.5 to 7).

CONCLUSIONS

SYBR Green I LightCycler based real-time polymerase chain reaction assay in urine samples is highly sensitive and specific, and easy to perform. It could provide the clinician with results in less than 5 hours. The technique could be a practical and useful tool for the rapid diagnosis of genitourinary complications of human brucellosis.

Brucella epididymo-orchitis: a consideration in endemic area

Brucellosis is a zoonotic disease caused by Brucella sp. and may affect many parts of the body. Brucella epididymo-orchitis had been reported in up to 20% of patients with brucellosis. This is a case report of Brucella epididymo-orchitis in a Saudi male patient. He presented with a unilateral swelling of the left testicle. He had fever, arthralgia and night sweats. Ultrasound examination revealed enlarged left epididymis and testicle. Brucella serology was positive and the patient responded to treatment with doxycycline and gentamicin. Thus, brucella infection should be considered in the differential diagnosis of patients presenting with epididymo-orchitis from an endemic area.