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Keywords:

  • abscess;
  • brucellosis;
  • testis

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Case report
  5. Discussion
  6. References

Abstract  We report on a case of a 32-year-old man referred for evaluation of a painless left testicular mass suggesting a testicular tumor. Previous history was uneventful except for a 3-year history of systemic brucellosis without epididymo-orchitis. Radical inguinal orchidectomy was performed. Clinical and histopathological findings indicated a brucellar abscess of the left testis. Even in the absence of systemic symptoms, the possible relapse of brucellosis as an abscess formation in the testis should be considered as a rare cause of testicular mass in patients who live in endemic regions.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Case report
  5. Discussion
  6. References

Brucellosis, a zoonosis, is a multiorgan infectious disease. The sources of infection are sheep, cattle, goats, dogs, swine, reindeer and camels. Transmission to humans occurs from direct contact via skin abrasions and mucous membranes or from the inhalation and ingestion of contaminated animal products, such as milk products, meat and body fluids.1 The genitourinary system is be affected in 2–20% of the cases with brucellosis and the most common form is seen as orchitis.1–5 Up to 10% of patients with systemic brucellosis relapse after antimicrobial therapy.1,2 Relapse may occur due to intracellular localization of the organisms, which protects the bacteria from certain antibiotics and host defense mechanisms, inadequate treatment or a continuation of the patients’ occupation. The relapse of brucellosis as an abscess formation in the testis was the only presenting feature of the case presently described.

Case report

  1. Top of page
  2. Abstract
  3. Introduction
  4. Case report
  5. Discussion
  6. References

A 32-year-old man was referred to our clinic with a 2-month history of a painless left testicular mass and a possible diagnosis of a testis tumor. Previous history was uneventful except for a 3-year history of systemic brucellosis without epididymo-orchitis. He had been treated with rifampicin plus doxycycline with a complete recovery including normalization of serum standard tube agglutination test (STA). Upon examination the right testis was palpated normally but the left testis was found indurate, without tenderness. There was no sign of inguinal lymphadenomegaly or abdominal organomegaly. Testicular ultrasonography showed a hypoechoic,  completely  heterogeneous  63 × 42 × 38 mm left intratesticular mass which was not hyperemic on color flow Doppler imaging (Fig. 1). The sonographic appearance appeared to be compatible with a non-seminomatous tumor. Concerning testis tumor markers, β human chorionic gonadotropin and α-fetoprotein were negative. The leukocyte count was 15100/µL. His serum STA test for brucellosis was positive at 1/80 titers. These data suggested abscess-forming brucellar orchitis, although a tumor diagnosis could not be discarded. The patient underwent a left radical inguinal orchidectomy. Macroscopic analysis of the specimen showed a solid, gray-white mass, leading to an almost complete destruction of the testis (Fig. 2a). Histological examination confirmed chronic granulomatous inflammation of the left testis, containing dense lymphoplasmacytic infiltration (Fig. 2b). A Ziehl-Neelsen stain for acid resistant bacilli was negative. Together with clinical and pathological findings, the diagnosis of the patient was confirmed as brucellar abscess of the left testis. Following diagnosis, 1 g/day ciprofloxacin plus 200 mg/day doxycycline were used for the treatment for 6 weeks. The patient recovered clinically and the STA titers were found to be undetectable after 2 months.

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Figure 1. Testicular ultrasonography showing a hypoechoic and heterogeneous left intratesticular mass with an intermittent necrotic focus.

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image

Figure 2. (a) Radical orchidectomy specimen showing a solid testicular mass with central necrosis and abscess formation. Arrows indicate remaining normal testis tissue. (b) Low power view of testis sections demonstrating granulomatous inflammation around atrophic seminiferous tubules (HE × 100).

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Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Case report
  5. Discussion
  6. References

In Turkey, like in other Mediterranean countries, brucellosis is frequently encountered.6B. Melitensis infection, distributed in the Mediterranean region, accounts for the majority of cases. In acute brucellosis cases, positive blood cultures are obtained in only 10–30% of cases and positivity decreases with increasing duration of illness. Therefore, most cases of brucellosis are diagnosed by STA test. In chronic localized brucellosis, STA titers may absent or low (below 1/160) owing to the prozone phenomenon which indicates the presence of immunoglobulin A and G blocking antibodies.2 Brucellar orchitis is diagnosed serologically, ultrasonographically and by the presence of symptoms, such as fever, testicular pain, enlargement and redness. Although the most common form in the genitourinary system is orchitis, prostatitis and testicular abscesses may also be seen in as a complication of primary infection.1–5

The treatment of brucellosis with drugs, such as rifampicin, doxycycline, tetracycline, ciprofloxacin, cotrimoxazole and streptomycin has been found to be found effective in 90% of cases, with a relapse rate of approximately 10%.1,2 Relapse can occur as long as 2 years after apparently successful treatment. However, relapse only occurred in orchitis form with systemic symptoms.5,7 To our knowledge, this is the first relapse case of brucellosis diagnosed with an isolated testicular abscess and without systemic symptoms. Because this region of Turkey is endemic for brucellosis, we used the treatment regimen (1 g/day ciprofloxacin plus 200 mg/day doxycyline) recommended by World Health Organization. Despite the progress in therapy regimens, orchidectomy may be performed after the development of testicular abscesses and a poor response to therapy in primary brucellosis.8 We also performed orchidectomy after observing the almost complete destruction of the testis. In the present case, relapse might have occurred due to the continuation of alimentation with contaminated products. In conclusion, brucellosis should be considered as a rare cause of testicular mass, especially in patients who live in endemic regions.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Case report
  5. Discussion
  6. References
  • 1
    Shapino DS, Wong JD. Brucella. In: MurayPR, BaronEJ, PfallerMA, TenoverFC, YolkenRH (eds). Manual of Clinical Microbiology, 7th edn. ASM Press, Washington, 1999; 62531.
  • 2
    Salata RA. Brucellosis. In: GoldmanL, BennetJC (eds). Cecil Textbook of Medicine. 21st edn. Saunders, Philedelphia 2000;171719.
  • 3
    Arruza A, Pertusa C, Zabala JA, Li Arena R. Genital Brucellosis. Arch. Esp. Urol. 1990; 43: 6734.
  • 4
    Khan MS, Humayoon MS, Al Manee MS. Epididymo-orchitis and brucellosis. Br. J. Urol. 1989; 63: 879.
  • 5
    Kadikoylu G, Tuncer G, Bolaman Z, Sina M. Brucellar orchitis in Innerwest Anotolia Region of Turkey. A report of 12 cases. Urol. Int. 2002; 69: 335.
  • 6
    Colak H, Usluer G, Karaguven B, Kose S, Ozgunes I. Seroepidemiological studies of brucellosis in urban areas. Infeksiyon Dergisi 1991; 5: 836. (In Turkish).
  • 7
    Valero Puerta JA, Medina Perez M, Marin Martin J, Sanchez Gonzales M, Valpuesta Fernandez I, Alvarez Kindelan J. Relapse in Brucella ochiepididymitis. Actas Urol. Esp. 1999; 23: 7268.
  • 8
    Gonzalez SFJ, Encinas GMB, Napal LS, Rajab R. Brucellar orchiepididymitis with abscess. Arch. Esp Urol. 1997; 50: 28992.