Stesura Seveso Archivio Italiano di Urologia e Andrologia 2023; 95(4):11978 1 ORIGINAL PAPER of infection, particularly in developing countries where there is inadequate control over animal infections. While the prevalence of brucellosis in developed countries is cur- rently minimal, isolated cases do arise within occupation- al cohorts at risk, such as farmers, veterinarians, and lab- oratory and slaughterhouse personnel (3). Brucellosis is linked to a range of genitourinary infections in males, such as brucellar epididymo-orchitis (BEO), cystitis, prostatitis, interstitial nephritis, pyelonephritis, exudative glomeru- lonephritis, the formation of renal and testicular abscess- es, and seminal vesiculitis (3). BEO is an infrequent com- plication of brucellosis, occurring in 5.7% of cases, and it is commonly unilateral. The prevailing symptoms encom- pass fever, scrotal pain, and swelling, chills or rigors, malaise, generalized discomfort, fatigue, and headache. The incidence and nature of complications are contingent upon the specific strain of the infecting Brucella, the patient's age, and the duration of the illness (1, 3, 4). It typically affects young and middle-aged individuals, and failure to prompt diagnosis or inadequate management can lead to various complications, such as testicular abscess, necrotizing orchitis, atrophy, infarction, suppura- tive necrosis, infertility, tumor, and aspermia (5, 6). Furthermore, the disease can mimic testicular tumors and tends to recur more than once, which makes it more chal- lenging (1, 7). Despite the higher incidence and morbidi- ties of brucellosis in developing countries, few case series on BEO are available in the literature (5, 8-13). The cur- rent study is a single-center experience focusing on the clinical manifestations, diagnosis, and treatment outcomes of BEO, with a literature review of the published case series. The references have been inspected for credibility based on the most up-to-date criteria (14). METHODS Study design This study was a single-center case series involving con- 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 presen- tations, diagnosis, and treatment of BEO with a review of the literature. This study included consecutive BEO patients diag- nosed 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 labora- tory 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 orchiecto- my due to the abscess formation. All the patients responded well to the treatment, with no recurrence. In the Middle East, brucel- losis remains a concerning infectious disease. Early diagnosis, aimed at preventing abscess formation and other complications, takes first priority to avoid invasive interventions. KEY WORDS: Brucellosis; Brucella; Orchitis; Genitourinary infection; Orchiectomy; Zoonosis. Submitted 14 October 2023; Accepted 7 November 2023 INTRODUCTION Brucellosis, known as Malta fever, is a zoonotic multiorgan disease caused by infection with Brucella species. The major sources of infection are dogs, sheep, cattle, goats, swine, camels, and reindeer. Human infection can occur through direct contact, inhalation of the microbe, con- sumption of contaminated meat, or ingestion of unpas- teurized milk (1, 2). Millions of people globally are at risk Brucella epididymo-orchitis: A single-center experience with a review of the literature Rawa Bapir 1, 2, 3, Ahmed Mohammed Abdalqadir 2, Esmaeel Aghaways 4, Hemn Hussein Bayz 5, Hiwa O. Abdullah 1, 3, Shaho F. Ahmed 1, Berun A. Abdalla 1, 3, Jihad Ibrahim Hama 6, Bryar Othman Muhammed 5, Karokh Fadhil Hamahussein 1, 7, Farman Mohammed Faraj 2, Fahmi Hussein Kakamad 1, 3, 4 1 Smart Health Tower, Madam Mitterrand Street, Sulaimani, Kurdistan, Iraq; 2 Department of Urology, Sulaimani Surgical Teaching Hospital, Sulaimani, Iraq; 3 Kscien Organization, Hamdi Street, Azadi Mall, Sulaimani, Kurdistan, Iraq; 4 College of Medicine, University of Sulaimani, Madam Mitterrand Street, Sulaimani, Kurdistan, Iraq; 5 Smart Health Tower Raparin, Rania, Sulaimani, Kurdistan, Iraq; 6 Research Center, University of Halabja, Halabja, Iraq; 7 Kurdistan Center for Gastroenterology and Hepatology, Sulaimani, Kurdistan, Iraq. DOI: 10.4081/aiua.2023.11978 Summary Archivio Italiano di Urologia e Andrologia 2023; 95(4):11978 R. Bapir, A.Mohammed Abdalqadir, E. Aghaways, et al. 2 secutive BEO patients diagnosed and treated at the urol- ogy clinic of Smart Health Tower (SHT) between January 2021 and January 2023. Patients provided explicit con- sent to partake and to authorize the publication of any related data in this study. The study was ethically evalu- ated by the scientific committee of SHT. Data collection After data de-identification, the required data were retro- spectively collected from patients' profiles within the urology clinic's database. The extracted information included patient demographics, occupation, clinical pre- sentations, laboratory findings [erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), complete blood count, liver function tests, Rose Bengal test (RBT), anti- Brucella antibodies (IgG and IgM) by the enzyme-linked immunosorbent assay (ELISA), and urine culture], ultra- sound (U/S) examination, strategy and outcome of treat- ment, and follow-up. Diagnosis strategy The diagnosis of brucellosis was established based on clinical symptoms consistent with brucellosis, a positive RBT, and positive anti-Brucella antibodies (IgG and IgM) on the ELISA. The BEO was diagnosed when patients had pain and swelling of the scrotum with enlarged tes- ticles and/or epididymis during the physical examina- tion. The BEO diagnosis was confirmed by scrotal Doppler U/S in cases with a positive RBT and positive IgG and IgM results for brucellosis. The U/S features of BEO were testicular vascularity, enlargement, non- homogenous echotexture, and heterogeneous or hypoe- choic echogenicity. Eligibility criteria All the confirmed cases of BEO who were diagnosed and managed in SHT between 2021 and 2023 were enrolled in this study. Statistical analysis The arrangement and coding of the data were performed using Microsoft Excel 2019. For qualitative data analysis (descriptive statistics), the Statistical Package for the Social Sciences (SPSS) Version 25 was utilized. The data were presented as means, frequencies, and percentages. Literature review Overall, 15 studies with 393 cases were reviewed in this series, of which most were conducted in Turkey (53.3%), followed by Iran (20%) and one study per Kuwait, Saudi Arabia, Greece, and Spain (3-5, 8-13, 15-20). The raw data of each reviewed study is shown in Table 1. The mean age of the cases was 34.5 ± 2.71, and most of them (76.6%) were at risk of infection as they either had close contact with animals or used raw meat and unpasteurized milk products. The right and left sides were affected near- ly equally, and bilateral involvement has been reported in 51 cases (13%). The major reported symptoms were fever (79.4%), pain (77.9%) and swelling (70%) of the testicles or scrotum, and sweating (57%) (Table 2). The three most commonly reported abnormal laboratory findings were high ESR (63%), CRP (57.3%), and WBC (29.8%). In all cases, the diagnosis was primarily based on clinical findings, with confirmatory tests including Brucella anti- gen tests (97.5%), Doppler U/S (63.6%), and positive blood cultures (23.2%). Doppler U/S found 7 cases (1.8%) of testicular abscesses. The majority of cases (95.4%) underwent conservative treatment with antibi- otics, while orchiectomy and drainage procedures were conducted in 2.8% and 0.3% of cases, respectively. A good outcome was achieved in 97.7% of patients, where- as nine cases (2.3%) failed to respond to the treatment. Table 1. Raw data of each reviewed series on BEO, or Brucella orchitis. Author Country No. Risk factors Age Major Symptoms Symptoms Duration Affected (year) Case (mean) (mean/day) site Animal contact RMMPI Fever Chills TSS TSP Sweating Arthralgia Dysuria Anorexia Headache R L Both Alarbid et al (2023) (8) Kuwait 11 8 0 32.5 10 0 0 0 0 0 0 0 0 N/A N/A N/A N/A Khodadadi et al (2023) (5) Iran 50 11 15 38.1 32 31 30 45 30 17 0 12 3 11.26 10 14 26 Gozdas et al (2020) (9) Turkey 25 14 15 36 16 0 25 25 12 14 4 12 0 20 N/A N/A 2 Naz et al (2016) (15) Turkey 21 14 16 44.6 14 0 13 21 7 10 0 2 0 N/A 10 10 1 Aydemir et al (2015) (4) Turkey 6 2 0 39 3 1 4 5 1 2 2 0 0 22* 3 2 1 Savasci et al (2014) (10) Turkey 28 N/A N/A 31 9 8 28 28 10 1 8 8 0 N/A 11 16 1 Gonen et al (2013) (16) Turkey 14 6 11 41 ** 12 0 N/A N/A 10 4 0 0 0 ≤ 30 8 6 0 Sofian et al (2013) (17) Iran 40 19 20 40 37 0 N/A N/A 36 20 13 0 0 ≤ 30 12 16 12 Güneş et al (2010) (18) Turkey 15 5 10 27 14 3 15 15 12 8 0 0 0 <14->42 9 5 1 Celen et al (2009) (3) Turkey 27 2 25 28.2 24 16 21 27 19 20 6 13 10 N/A N/A N/A 2 Roushan et al (2009) (13) Iran 53 37 4 35.5 43 0 54 54 40 12 0 0 0 29 30 22 1 Colmenero et al (2007) (19) Spain 48 9 11 36.6 48 42 48 48 40 0 2 0 0 52.5 21 25 2 Papatsoris et al (2002) (20) Greece 17 17 8 30.1 13 0 0 0 0 0 4 0 0 N/A N/A N/A N/A Kadikoylu et al (2002) (11) Turkey 12 12 N/A 30 12 0 12 12 6 0 0 3 0 N/A N/A N/A N/A Memish et al (2001) (12) Saudi Arabia 26 N/A 10 N/A 25 14 26 26 1 6 4 3 4 <14->42 15 9 2 RMMPI: Raw meat or milk product ingestion; N/A: non-available; TSS: testicular or scrotal swelling; TSP: testicular or scrotal pain; R: right; L: left; CRP: C-reactive protein; WBC: white blood cell; ESR: erythrocyte sedimentation rate, ALT: Alanine transaminase; AST: Aspartate aminotransferase; ALP: Alkaline Phosphatase; U/S: Ultrasound; CSV: conservative; OT: orchiectomy; UNK: unknown. * The duration is for only 4 cases. ** Median age. Archivio Italiano di Urologia e Andrologia 2023; 95(4):11978 3 Brucella epididymo-orchitis During the follow-up periods, which were different for each study, 11 cases (2.8%) of recurrence have been doc- umented (Table 2). RESULTS This study included 11 cases whose ages ranged from 22 to 55 years, with a median and mean age of 31 and 35.3 ± 12.12, respectively. More than half of the cases were workers (55%), and the remaining were shepherds (27%), a butcher, and a student. The majority of the cases presented with testicular pain (72.7%), followed by fever (63.6%), arthralgia (63.6%), sweating (45.5%), and scro- tal swelling (45.5%). Regarding the laterality, the right side (54.5%) was slightly more affected than the left side (45.5%). Abnormal laboratory findings were elevated CRP (82%), anemia (27.3%), elevated WBC (18.2%), low WBC (9%), and elevated alanine transaminase (ALT) (9%). In addition, RBT and IgG and IgM antibodies for Brucella were positive in all the cases. The treatment strat- egy was conservative, in which a combination of gentam- icin, doxycycline, and rifampicin was administered to all Table 2. Summary of the published series on BEO, or Brucella orchitis. Variables Frequency/Percentage Country of studies Turkey 8 (53.3%) Iran 3 (20%) Kuwait 1 (6.7%) Saudi Arabia 1 (6.7%) Greece 1 (6.7%) Spain 1 (6.7%) Demographic data Age (mean of means) ± SD 34.5 ± 2.71 Risk factors Contact with animal 156 (39.7%) Raw meat or milk product ingestion 145 (36.9%) Affected site Right side 129 (32.8%) Left side 125 (31.8%) Bilateral 51 (13%) N/A 124 (31.5%) Major symptoms * Fever 312 (79.4%) Testicular or scrotal pain 306 (77.9%) Testicular or scrotal swelling 276 (70%) Sweating 224 (57%) Chills 115 (29.3%) Arthralgia 114 (29%) Anorexia 53 (13.5) Dysuria 43 (11%) Headache 17 (4.3%) Variables Frequency/Percentage Abnormal Laboratory findings * High ESR 248 (63%) High CRP 225 (57.3%) High WBC 117 (29.8%) Positive blood culture 91 (23.2%) High ALT 65 (16.5%) High AST 49 (12.5%) High ALP 23 (6%) Anemia 39 (10%) Positive urine culture 1 (0.3%) Diagnostic tools Brucella antigen tests 383 (97.5%) Scrotal Doppler ultrasound 250 (63.6%) Positive blood culture 91 (23.2%) Testicular abscess 7 (1.8%) Treatment Conservative (antibiotics) 375 (95.4%) Orchiectomy 11 (2.8%) Drainage 1 (0.3%) Unknown 11 (2.8%) Outcome Good 384 (97.7%) Failure 9 (2.3%) Follow-up Recurrence 11 (2.8%) * Other symptoms and laboratory findings have been reported in the reviewed studies, but this study reviewed the most common of them. Abnormal Laboratory findings Diagnosis tools Abscess Treatment Outcome Recurrence CRP WBC ESR ALT AST ALP Anemia Blood culture Urine culture Brucella antigen test Positive Blood Culture U/S CSV OT Drainage N/A N/A N/A N/A N/A N/A 0 11 N/A 11 11 0 0 UNK UNK UNK All Good 0 30 13 30 15 9 16 0 0 1 50 0 50 0 50 0 0 All Good 0 22 4 12 12 6 N/A 8 1 N/A 25 1 21 1 25 0 1 All Good 0 17 3 11 N/A N/A N/A 6 8 N/A 21 8 18 0 21 1 0 2 failures 2 6 2 3 N/A N/A N/A 0 2 0 6 2 5 0 6 0 0 All Good 0 20 18 19 14 11 N/A 1 5 N/A 28 5 28 2 21 7 0 4 failures 0 14 3 13 8 7 N/A 1 4 0 14 4 1 0 14 0 0 All good 1 27 10 29 N/A N/A N/A 22 N/A N/A 40 0 0 1 40 0 0 All good 0 15 6 10 7 8 N/A 1 0 N/A 15 0 0 1 15 1 0 All good 0 26 10 25 9 8 5 0 10 0 27 10 27 0 27 0 0 All good 1 N/A 19 41 N/A N/A N/A N/A 8 0 53 8 53 1 53 2 0 6 Failures 1 48 7 30 N/A N/A N/A N/A 27 0 39 27 18 1 48 0 0 1 Failure 3 N/A 6 13 N/A N/A N/A N/A 9 0 17 9 17 0 17 0 0 All good 0 N/A 10 4 N/A N/A N/A 0 2 N/A 12 2 12 0 12 0 0 All good 2 N/A 6 8 N/A N/A 2 0 4 0 25 4 0 0 26 0 0 All good 1 Archivio Italiano di Urologia e Andrologia 2023; 95(4):11978 R. Bapir, A.Mohammed Abdalqadir, E. Aghaways, et al. 4 the cases for about 6-8 weeks (Table 3). One case under- went orchiectomy as a secondary treatment due to the abscess formation. All the patients responded well to the treatment. After more than 2 years of follow-up for the first case and one year for the newest case, no recurrence has yet been reported. DISCUSSION Brucellosis represents an endemic multisystemic infectious disease within specific geographical areas such as the Middle East, the Arabian Peninsula, the Mediterranean region, and India. Its prevalence is significantly greater in rural environments in comparison to urban settings (1). The disease is commonly reported in developing countries; however, it can also be seen in developed countries due to immigration and travel (19). It has been reported that the preponderance of the cases is affected during the spring and summer, which may be caused by consuming milk products and fresh cheese more commonly in the spring (3). The review of the literature revealed that the majority of the cases were reported in Turkey, followed by Iran, which supported the previous claim. In addition, two reviewed studies were conducted in developed countries like Greece and Spain (19, 20). The major risk factors for BEO are direct contact with animals, inhalation of infectious aerosols, and ingestion of raw meat or unpasteurized milk products (1, 7). Among the 393 reviewed cases, 76.6% were at risk of infection (3-5, 8-13, 15-20). In the present study, three cases were shepherds and one was a butcher, whereas for the remaining seven cases, it was unknown whether they had a risk factor for infection or not. Scholars reported a higher susceptibility to infection among young males. Savasci et al. conducted a retrospec- tive analysis of 28 cases of BEO, revealing that the major- ity of cases occurred between the second and third decades of life, with an average age of 31 years (10). In accordance with that finding, the mean ages of the reviewed and present cases were 34.5 and 35.3 years, respectively. This raises a noteworthy concern, as brucel- losis could potentially exert adverse effects on the repro- ductive outcomes of sexually active young adults (9). In around 20-40% of cases, Brucella orchitis is considered to stem directly from epididymitis (1). A study by Baykan et al. found that approximately 67% of 24 male cases showed involvement of both the epididymis and testes (21). While Celen et al. reported a bilateral testis involve- ment rate of less than 10%, Baykan et al. recorded a rela- tively higher rate of 21% (3, 21). The bilateral involve- ment in the reviewed literature was 13%, which is more compatible with Celen et al. than Baykan et al. In the pres- ent series, there was no bilateral involvement, and epi- didymo-orchitis was found in about 55% of the cases. In general, BEO patients have acute symptoms for about two weeks at the time of presentation (22). The primary manifestations of brucellosis can be fever, chills, sweating, nausea, vomiting, myalgia, arthritis, and osteoarticular involvement. In addition to previous symptoms, scrotal pain and swelling may be indicators of BEO (1). Among the 15 reviewed studies, the prevalent reported symptoms were fever (79.4%), scrotal pain (77.9%), scrotal swelling (70%), and sweating (57%). In line with the literature, the most common presentations in our cases were testicular pain (72.7%), fever (63.6%), arthralgia (63.6%), sweating (45.5%), and scrotal swelling (45.5%). Regarding the incidence of BEO in patients with brucel- losis, it has been reported to occur in 2% to 20% of the cases (1). In their study, Celen et al. documented 27 (18.8%) cases of BEO within a cohort of 143 patients with brucellosis. Meanwhile, Papatsoris et al. identified 25 (2.5%) BEO cases among a group of 995 cases with bru- cellosis (3, 20). To distinguish BEO from non-specific epididymo-orchitis, several factors have been reported to be considered, such as animal contact history, consump- tion of raw milk or cheese, gradual onset, extended dura- tion, distinctive undulant fever, mild local inflammation, and the lack of lower urinary tract symptoms alongside insignificant leukocytosis (22). On the contrary, Celen et al. mentioned WBC as an important indicator of BEO (3). All the cases in the reviewed studies and in the present study had more than one of the distinguishing factors. Variables Frequency/Percentage Demographics Age range (median, mean ± SD), years 20-55 (31, 35.3 ± 12.12) Occupation Worker 6 (55%) Shepherd 3 (27%) Butcher 1 (9%) Student 1 (9%) Clinical presentations Testicular pain 8 (72.7%) Fever 7 (63.6%) Arthralgia 7 (63.6%) Sweating 5 (45.5%) Scrotal swelling 5 (45.5%) Right 3 (27.3%) Left 2 (18.2%) Splenomegaly 4 (36.4%) Chills 4 (36.4%) Affected site Right Side 6 (54.5%) Left Side 5 (45.5%) Laboratory findings Elevated CRP (> 5 mg/dL) 9 (82%) Anemia (< 13 g/dL) 3 (27.3%) Elevated WBC (> 11000) 2 (18.2%) low WBC (< 4000) 1 (9%) Elevated ALT (> 50 IU/L) 1 (9%) Positive Rose Bengal test 11 (100%) Positive IgG and IgM for Brucella 11 (100%) Ultrasonography findings Vascularity 10 (91%) Testicular enlargement 7 (63.6%) Heterogenous texture 6 (54.5%) Heterogenous echogenicity 4 (36.4%) Unretrieved 1 (9%) Diagnosis Epididymo-orchitis 6 (54.5%) Orchitis 5 (45.5%) Treatment therapy (Duration) Gentamicin + Doxycycline + Rifampicin (6-8 w) 11 (100%) Secondary treatment Orchiectomy 1 (9%) Table 3. Baseline characteristics of the BEO patients. Archivio Italiano di Urologia e Andrologia 2023; 95(4):11978 5 Brucella epididymo-orchitis A high WBC was reported in 29.8% of the reviewed cases and 18.2% of the present cases, which may not support the observation of Celen et al. (3). Distinguishing between BEO and non-specific epididymo- orchitis is crucial, as treatment delay raises the chance of contralateral involvement, tissue necrosis, and systemic symptoms. Thus, in regions where brucellosis is endemic, having a suspicion alone justifies commencing therapy while waiting for definitive lab test results (8, 21). Another challenge in the diagnosis of BEO is mimicking the disease as a testicular tumor, epididymitis, trauma, hematocele, or torsion of the testis (1, 4). Aydemir et al. reported a case of BEO that was diagnosed as a testicular tumor based on a U/S examination and later confirmed to be BEO by con- ducting tumor markers, magnetic resonance imaging (MRI), and tube agglutination tests. In another study, Bapir et al. (1) reported a misdiagnosed case of BEO that appeared as a tumor in both Doppler U/S and MRI. Then, the diagno- sis was corrected using tumor markers and an RBT test. The diagnosis of Brucella orchitis can be established by considering a combination of serology, ultrasonography, and the existence of typical symptoms such as fever, testic- ular pain, enlargement, and inflammation (1). The primary diagnostic approach for brucellosis is the serum agglutina- tion test, and a positive result is defined as a titer ratio exceeding 1:160 when accompanied by distinct clinical symptoms. Nevertheless, in cases of prolonged brucellosis, agglutination test titers might be absent or below 1:160 (1). In such instances, the disease can be detected better by using other serologic tests like Coombs’ anti-Brucella test, immunocapture agglutination test, 2-mercaptoethanol agglutination test, or ELISA, as the immune response to the infection causes an initial increase in IgM antibodies fol- lowed by a switch to increasing IgG antibodies within a few weeks of infection (19). In total, 97.5% of the cases in the reviewed studies were diagnosed based on the various Brucella antigen tests. Due to the mentioned drawback of the serum agglutination test, all the cases in the present study were diagnosed by RBT and ELISA tests. Abnormal blood investigation findings are often mild and not very specific. Prolonged infection might cause a slight drop in hemoglobin levels, and a moderate increase in ESR is commonly seen. Liver function tests may show a mild to moderate elevation in ALT and aspartate amino- transferase (AST) levels. A high CRP level is a noteworthy finding in most cases (3, 17). Colmenero et al. reported a positive blood culture in 65.8% of patients with brucel- losis and stated the necessity of the method in diagnosing brucellosis. Furthermore, the positivity of blood culture in BEO cases has been reported to be 53-69% (22). The most significant laboratory findings in the reviewed stud- ies were positive Brucella antigen tests (97.5%), high ESR (63%), and CRP (57.3%). In contrast to the previous findings, the blood culture was positive in only 23.2% of the 393 reviewed cases. In the present study, an elevated CRP was the dominant finding (82%), after positive RBT (100%) and ELISA (100%). No blood culture was con- ducted in this study because the diagnosis of brucellosis was based on RBT and ELISA. Ultrasonography is usually vital for excluding the suspi- cion of an abscess or tumor rather than confirming the pri- mary diagnosis. The frequent U/S features of BEO are tes- ticular enlargement, hypervascularity, inhomogeneous echotexture, and heterogeneous or hypoechoic echogenic- ity. These features can also be seen in other etiologies of orchitis. Thus, the U/S examination cannot be relied on solely for the diagnosis of BEO (1, 9). All these features could be seen in the U/S examination of our cases, of which vascularity was the most prevalent finding (91%). It has been indicated that using medications like rifampicin, streptomycin, tetracycline, ciprofloxacin, doxycycline, and cotrimoxazole for at least six weeks has a significant impact on managing brucellosis (1). A suggested approach involves taking a daily combination of doxycycline (200 mg) and rifampicin (600 mg) for around six weeks. It's worth noting that using a single drug for treatment has a higher likeli- hood of failure compared to using a combination, so med- ical treatment should involve the use of two or three antibi- otics together (1, 10, 21). The rate of treatment failure and the requirement for orchiectomy have been reported to vary from 0% to 40% and from 0% to 5.1%, respectively. In accordance, the rates of treatment failure, recurrence, and orchiectomy among the reviewed cases were 2.3%, 2.8%, and 2.8% consecutively. All patients in this series were treated with antibiotic combinations. One orchiecto- my (9%) was conducted due to abscess formation, and no recurrence was reported during the follow-up period. CONCLUSIONS In developing countries, especially in the Middle East, brucellosis remains a concerning infectious disease. As it is commonly diagnosed in young adults, it may have unfavorable effects on the reproductive activity of this group. 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Correspondence Rawa Bapir, MD Dr.rawa@yahoo.com Hiwa Abdullah, MD hiewaom96@gmail.com Shaho Ahmed, MD shahomedi87@gmail.com Berun Abdalla, MD berun.anwer95@gmail.com Smart Health Tower, Madam Mitterrand Street, Sulaimani, Kurdistan, Iraq Esmaeel Aghaways, MD esmaeel.aghaways@gmail.com College of Medicine, University of Sulaimani, Madam Mitterrand Street, Sulaimani, Kurdistan, Iraq Hemn Bayz, MD hemn.bayz@gmail.com Smart Health Tower Raparin, Karux Str, Rania, Sulaimani, Kurdistan, Iraq Jihad Hama, MD jihad.hama@gmail.com Bryar Muhammed, MD bryar.muhammed@gmail.com Research Center, University of Halabja, Halabja, Iraq Karokh Hamahussein, MD karokh12@gmail.com Kurdistan Center for Gastroenterology and Hepatology, Sulaimani, Kurdistan, Iraq Farman Faraj, MD farman.faraj@gmail.com Ahmed Abdalqadir, MD ahmed.abdalqadir@gmail.com Department of Urology, Sulaimani Surgical Teaching Hospital, Sulaimani, Iraq Fahmi Hussein Kakamad, MD (Corresponding Author) fahmi.hussein@univsul.edu.iq College of Medicine, University of Sulaimani Doctor City, Building 11, Apartment 50 Madam Mitterrand Street, HC8V+F66, 46000 Sulaymaniyah, Kurdistan, Iraq Conflict of interest: The authors declare no potential conflict of interest.