Stesura Seveso


151Archivio Italiano di Urologia e Andrologia 2015; 87, 2

SHORT COMMUNICATION

Different presentation types 
of primary Brucella epididimo-orchitis

Huseyin Aydemir 1, Gokcen Budak 2, Salih Budak 3, Orcun Celik 3, Okan Yalbuzdag 3, !brahim Keles 4

1 Department of Urology, Ministry of Health Sakarya Teaching and Research Hospital, Sakarya, Turkey;
2 Department of Infectious Disease Clinic, Tire State Hospital, Sakarya, Turkey;       
3 Tepecik Educational and Research Hospital, Department of Urology, Izmir, Turkey;
4 Department of Urology, School of Medicine, Afyon Kocatepe University, Afyonkarahisar, Turkey.

Brucellosis is a zoonotic disease that
involved genitourinary system in 2-20%

and most commonly cause single sided epididymo-orchitis. 
In our country Brucella is an endemic disease and causes
serious and different diagnosis of acute scrotum and epididy-
moorchitis. In this paper six cases of epididymo-orchitis
cases which were resistant to classical treatment were dis-
cussed according to clinical and laboratory findings. 
We describe different types of presentation of Brucella epi-
didymoorchitis with diagnosis and treatment modalities. 

KEY WORDS: Brucellosis; Testis; Epididymo-orchitis; Acute
 scrotum; Infection.

Submittec 5 November 2014; Accepted 28 January 2015

Summary

No conflict of interest declared.

Patient developed joint and muscle pain lately. At physi-
cal examination, body temperature was 37.2°C, swelling
on right testicle with extensive tenderness was present,
epididymis was hard, scrotum was erythematous and
local temperature increased. Examination of other sys-
tems was normal. Scrotal color Doppler ultrasonography
reported findings consistent with right epididymo-orchi-
tis. Laboratory findings included leucocytes 8700/mm3,
sedimentation rate 27 mm/h, CRP 30 mg/L and tube
agglutination test positive at 1/160 titers. There was no
growth in blood cultures. Patient was treated with
rifampicin 600 mg/day, doxycycline 200 mg/day and
anti-inflammatory treatment for 6 weeks. Symptoms
were regressed after first week of treatment. There was
no recurrence on the follow up. 

Case 2 (septicemia)
A 63 year old male patient working with farm animals,
presented with fever, night sweating and joint pain for
15 days For the last 2 days he had dysuria, swelling in
the right testicle and pain. Physical examination showed
37.8°C body temperature, right epididymis very tender
and swelling of the testicle, local erythema of the scro-
tum with temperature increase. Physical examination of
other systems was normal. Laboratory results showed
leucocyte count 13500/mm3, sedimentation rate 67
mm/h, CRP 70 mg/L, Brucella tube agglutination test
positive for 1/640 titer. Brucella spp. growth was docu-
mented in blood cultures. Whereas there was no growth
in urine culture. Patient’s treatment was planned for 6
weeks with rifampicin 600 mg/day, doxycycline 200
mg/day and anti-inflammatory treatment but in the sec-
ond week of his treatment testicular pain was not
regressed and patient continued to have frequent fever
(38°C). One g/day streptomycin IM was added to treat-
ment for two weeks and treatment was finished up to 6
weeks. After addition of streptomycin on the 3rd day of
treatment patient complaints were relieved dramatically.
There was no relapse in 18 months follow up. 

Case 3 (acute scrotum, septicemia)
A 27 year old male farmer presented with acute left tes-
ticular pain, fever, shivering, nausea and vomiting start-

DOI: 10.4081/aiua.2015.2.151

INTRODUCTION
Brucellosis is spread to humans by infected or contami-
nated animals and less than sufficiently pasteurized milk
and milk products (1, 2). Brucellosis can infect many
organs and present with different clinical symptoms (3).
Brucellosis infects genitourinary system in 2-20% and
most commonly causes single sided epididymo-orchitis
(3). Brucella epididymoorchitis (BEO) generally causes
acute clinical symptoms (78%) (3-5). Differential diag-
nosis of the disease with other emergency urological con-
ditions causing acute scrotum (testicular torsion, testicu-
lar tumors, etc.) must be conducted precisely to prevent
consequences of surgery. 
This paper is aimed to describe differential diagnosis of
epididymo-orchitis cases that are resistant to classical
treatment or recurrent considering diagnosis and treat-
ment of Brucellosis that still maintains its importance. It
also calls attention to different clinical pictures of
Brucella epididymoorchitis. 

CASE REPORTS

Case 1 (unsuccessful treatment)
A 42 years old male patient with right testicular pain,
edema and fever started 2 months before was treated
withoute success for recurrent orchitis in another center.

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Archivio Italiano di Urologia e Andrologia 2015; 87, 2

Aydemir Huseyin, Budak Gokcen, Budak Salih, Celik Orcun, Yalbuzdag Okan, Keles !brahim

152

ed one day before. At physical examination his body
temperature was 38.7°C and blood pressure was 90/60
mmHg, he had minimal swelling of left testis, severe ten-
derness whereas examination of other systems was nor-
mal. Laboratory findings showed leucocyte count
21000/mm3, sedimentation rate 50 mm/h, CRP 77 mg/L.
Scrotal color Doppler ultrasonography revealed finding
of left epididymo-orchitis. Patient was hospitalized,
monitored and treated with 2 g/day ceftriaxone. On the
3rd day of treatment, symptoms and vital findings were
not recovered enough, left testicular edema increased
dramatically and erythema and edema involved the left
side of scrotum. Brucella was suspected and Coombs test
for Brucella was positive, tube agglutination test was pos-
itive for 1/320 titer. In blood culture Brucella spp.
growth was observed. Patient was treated with rifampicin
600 mg/day, doxicycline 200 mg/day and streptomycin
1 gr/day IM. Vital findings were normalized after the 2nd

day of treatment. Testicular findings recessed after 2
weeks. Patient’s treatment was completed in 6 weeks
(streptomycin at 15th day). Patient did not have any
recurrence orchitis but due to recurrent arteritis patient
was transferred to specialized clinic.

Case 4 (nonspecific epididmoorchitis)
A 50 years old male patient presented with dysuria and
right testicular pain for 6 weeks. At physical examination
tenderness of right testicular and inguinal canal was
present, vital findings and other systems examination
was normal. In laboratory findings leucocyte count was
4500/mm3, sedimentation rate was 12 mm/h and CRP
was 9 mg/L. Scrotal color Doppler ultrasonography
showed findings consistent with right epididymo-orchi-
tis. Patient was treated with ciprofloxacin 100 mg/day. At
the 4th day of treatment patient presented again with
high fever and swelling of right testicle. Physical exami-
nation revealed swelling of right testicle, erythema and
temperature increase at the right side of the scrotum. His
body temperature was 38.2°C. Patient detailed history
revealed that he was treated for Brucellosis 6 months
prior. Brucellosis Coombs test was positive and tube
agglutination test was positive for 1/160 titer. There was
no growth in blood and urine cultures. Patient was treat-
ed with rifampicin 600 mg/day, doxycycline 200 mg/day
and anti-inflammatory drugs for 6 weeks. His symptoms
were diminished after the first week of treatment. There
was no recurrence in 6 months follow up of the patient. 

Case 5 (bilateral epididymoorchitis)
A 22 years old male patient presenting with long lasting
bilateral testicular pain. Physical examination showed
minimal tenderness of both testicles, vital findings and
other system examination were normal. Laboratory find-
ings showed no specific findings in urinary analysis, leu-
cocyte count 4100/mm3, sedimentation rate 8 mm/h, and
CRP 6 mg /L. Scrotal color Doppler ultrasonography
revealed bilateral testicular increased blood flow. Patient’s
family was treated for Brucellosis, so Brucellosis panel was
studied. Rose Bengal test was positive and tube agglutina-
tion test was positive for 1/160 titer. There was no growth
in blood or urine culture. Patient was treated with
rifampicin 600 mg/day, doxycycline 200 mg/day and anti-

inflammatory drugs for 6 weeks. Patient’s symptoms were
decreased after the 2nd week of the treatment. There was
no recurrence in the 3 month follow up of the patient. 

Case 6 (testicular tumor suspicion)
A 30 years old male patient presented to the urology
clinic with a left testicular painful mass. Physical exami-
nation revealed left testicular stiffness at palpation.
Examination of other system was normal. There was no
significant clinical or family history. Laboratory findings
included leucocyte count 10200/mm3, CRP 72 mg/L, α-
feto protein (AFP) 1.8 (< 13.4), BHCG < 1.2. Emergency
scrotal ultrasonographyshowed an hypodense 31.8 mm
solid mass of left testicle. After a preliminary diagnosis of
seminoma, magnetic resonance imaging (RMI) was
scheduled that demonstrated unclear demarcation of the
mass with heterogeneous pattern that was reported as
consistent with epididymo-orchitis (Figure 1). 
Brucella tube agglutination test was positive for 1/250
titer. There was no growth in blood culture. Patient was
treated with rifampicin 600 mg/day and doxycycline 200
mg/day. Pain and swelling regressed and scrotal ultra-
sonography 2 week after treatment showed dramatic
regression. Ultrasonography conducted 3 months later
showed further decrease of mass size and at 1 year follow
up ultrasonography findings were normal. There was no
recurrence at 2 years follow up.  

DISCUSSION
Brucellosis is very rare in developed countries. But it is an
endemic zoonotic disease in the Mediterranean basin and
Middle East (2). Turkey is in the Brucellosis endemic
region and its incidence is 2-6% (6). In systemic brucel-
losis, epididymo-orchitis is most commonly seen as uni-
lateral (3, 6, 7). In a study of 12 cases with genitourinary

Figure 1. 
Left testicular heterogeneous mass, consistent 
with epididymoorchitis. 

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153Archivio Italiano di Urologia e Andrologia 2015; 87, 2

Different presentation types of primary Brucella epididimo-orchitis

complications due to Brucellosis, 10 cases presented with
epididymoorchitis (5). In the same study the ten BEO
patients were compared with 15 non-specific epididy-
moorchitis (EO) cases and BEO was characterized by
long-lasting clinical presentation, history of unpasteur-
ized milk consumption, lower urinary system symptoms,
normal urinary analysis and frequent leukocytosis (5).
Some tests are required for the diagnosis of brucellosis,
in addition to patient history and physical examination
(rose bengal, tube agglutination, Coombs test, blood cul-
ture). Values of tube test higher of 1/160 titer and blood
culture positivity are important for diagnosis (8). 
Delayed diagnosis and treatment, can lead to various
complications (e.g., testicular abscess, atrophy, necrosis
and infertility) (9). It is very difficult to distinguish BEO
from non-specific EO (10). Detailed history from the
patient is important for diagnosis in case of EO unre-
sponsive to conventional therapy, that should bring to
mind brucella EO.
Acute epididymo-orchitis is a frequent disease in urolo-
gy clinic and one of the causes of acute scrotum. 
Differential diagnosis of acute scrotum includes testicular
torsion, testicular tumors, appendicular testicular torsion
and testicular trauma. Diagnosis of torsion and tumor are
crucial because they require fast treatment, so futher
radiological tests must be considered. In our 6th case,
even though ultrasonography diagnosis was consistent
with a testicular tumor MRI results demonstrated epi-
didymoorchitis. Tumor markers in the normal range and
tube agglutination test consistent with Brucellosis helped
the clinical diagnosis. In consideration of the association
of tumor and epididymo-orchitis, frequent and close fol-
low up is suggested.
World Health Organization recommends a 45 day course
of oral doxycycline 200 mg/day and streptomycin 1
g/day IM for Brucellosis treatment. An alternative is a 45
day course of oral rifampicin 15 mg/kg/day (600-800
mg) and doxycycline 200 mg/day (11). In cases unre-
sponsive to medical treatment orchiectomy is practiced.
Afsar et al. reported 2 cases requiring orchiectomy in a
13 cases study with doxycycline and rifampicin treat-
ment (12). 
In conclusion, Brucella epididymo-orchitis must be kept

in mind in the differential diagnosis of acute scrotum and
epididmo-orchitis in Brusella-endemic countries. 

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Correspondence
Aydemir Huseyin, MD
Department of Urology, Ministry of Health Sakarya Teaching and 
Research Hospital, Sakarya, Turkey

Gokcen Budak, MD
Department of Infectious Disease Clinic, Tire State Hospital
Sakarya, Turkey     

Salih Budak, MD (Corresponding Author)
salihbudak1977@gmail.com
Orcun Celik, MD
Okan Yalbuzdag, MD
Tepecik Educational and Research Hospital, Department of Urology
35140 Izmir, Turkey

!brahim Keles, MD
Department of Urology, School of Medicine, Afyon Kocatepe University
Afyonkarahisar, Turkey

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