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Conservative treatment for Brucella testicular abscesses: a case report and literature review.

Introduction

Brucellosis is a multi-organ infectious disease that can cause genitourinary manifestations. (1-4) Testicular abscesses are a rare complication. Although surgery is the standard treatment, medical therapy alone can be successful. We report a case of a 36-year-old man with multiple testicular abscesses caused by relapse of systemic brucellosis, and provide a literature review.

Case report

A 36-year-old man presented to the emergency department with left testicular pain of 6 weeks duration that increased in severity in the previous few days. His medical history was insignificant, except for systemic Brucella infection in the form of fever and rigors after ingestion of raw milk, treated 3 months ago.

On physical examination, the left hemi-scrotum was tender and swollen. No fever was documented. Laboratory studies, including complete blood count, kidney function tests, urine analysis and subsequent urine culture, were normal. The patient was suspected to have epididymo-orchitis. Consequently, scrotal ultrasound was performed, which revealed a swollen left testis with multiple parenchymal irregular anechoic cystic areas with thin internal septation. The overall vascularity of the left testis increased (Fig. 1). The right testis and both epididymides were normal. These radiological findings were suspicious for testicular abscesses.

In view of patient's history of Brucella, a possible relapse of Brucellosis in the form of testicular abscesses was proposed. While awaiting the opinion of the infectious team, the patient was administered ceftriaxone. Fine-needle aspiration was discussed with the radiology team, but was deemed unsuitable due to the multiplicity and small size of abscesses. We discussed with the patient the option of intraoperative drainage and possible partial orchiectomy, but he was reluctant. Accordingly, we started a trial of conservative therapy.

Further analysis, including blood culture, brucella titers and purified protein derivative (PPD) test for tuberculosis, were negative. However, because of the high index of suspicion of relapse of Brucellosis, a repeat of Brucella titer using a dilution of agglutination of Brucella was done. This was positive for brucella Melitensis, titer=1:320 (normal less than 1:80). Therefore, treatment changed to doxycycline 100 mg orally twice daily, ciprofloxacin 500 mg orally twice daily, and sulfamethoxazole and trimethoprim 960 mg orally twice daily for 2 weeks.

At the 1-week follow-up, the patient showed significant improvement clinically and some improvement sonographically. Hence, he was continued on the same treatment, and advised to follow-up after 2 weeks. At that time, the ultrasound was repeated and it showed marked reduction in the size of the abscesses as the largest one measured 4 mm in diameter (Fig. 2).

At the 6-week follow-up, the patient was doing well with complete resolution of his symptoms.

[FIGURE 1 OMITTED]

Discussion

This case documents the diagnosis of multiple testicular abscesses caused by Brucella species. The patient presented after a history of treated systemic Brucellosis with left testicular swelling and pain. An ultrasound revealed multiple small testicular abscesses, and the repeat diluted Brucella titer showed the causative pathogen. The patient was successfully treated with 3 months of oral targeted antibiotics, with no need for drainage or orchiectomy.

Brucellosis is a multi-organ infectious disease that is considered endemic in Mediterranean, (1,3,5-7) the Arabian gulf, and parts of Mexico, Central and South America. (7) It is caused by 4 Brucella species; B. abortus, B. melitensis, B. uis, and B. canis. (2) Brucella melitensis is the most common one, (3,4) which is concordant with the pathogen in our case. Direct contact with infected animals or ingestion of contaminated animal products are the main routes of human transmission. (1-3) The most common clinical findings are fever and osteoarticular involvement. (1) Genitourinary involvement in endemic areas ranges between 1.6% and 20%. (2-4) The most common genitourinary manifestation is orchitis; (2,4) however, intratesticular abscess is a rare complication.

A literature review revealed 9 cases of testicular abscesses caused by Brucella, 6 of which ended with orchiectomy, (3,4,8-11) while 2 needed drainage. (1,5) Only 1 case was treated by medical therapy alone (6) (Table 1). In most cases, there was relevant history that guided the clinician to think of Brucella as the causative pathogen. Moreover, imaging played an essential role in the diagnosis.

In acute Brucellosis cases, positive blood cultures are obtained in only 10% to 30% of cases and positivity decreases with increased duration of illness. Therefore, most cases are diagnosed by standard tube agglutination test. In chronic localized Brucellosis, standard tube agglutination test titers may be low due to prozone phenomenon which indicates the presence of immunoglobulin A and G blocking antibodies. (3) This happened in our case, so we relied on the dilution tests to confirm our suspicion. Brucella testicular abscesses can be diagnosed by the presence of related history, sonographic features of abscess, and serology.

In previously reported cases, orchiectomy was done either due to suspicion of tumour, or failed medical management. Even though the abscesses in those cases were larger than our case, we still think that medical treatment should be tried initially, particularly if the patient showed clinical improvement. The one patient treated by medical therapy alone also had a large abscess. (6) Although he improved clinically on subsequent follow-up, the abscess increased in size. Consequently, he was planned for orchiectomy, which he refused and returned 5 months later with regression of his abscess. (6)

Medical treatment is recommended for at least 6 weeks. Combined antibiotics, such as doxycycline, rifampicin, tetracycline, ciprofloxacin, and streptomycin, were described in the treatment of Brucella infections, (1,3,6) with rifampicin and deoxycycline being the preferred combination. (6) We used doxycycline, ciprofloxacin and bactrim since our patient was treated earlier with doxycycline and rifampicine for his systemic Brucellosis. Our patient showed marked improvement with antibiotic therapy, so we continued with oral therapy and avoided unnecessary orchiectomy.

[FIGURE 2 OMITTED]

Conclusion

Brucella as a case of testicular abscess/abscesses should be suspected in patients from endemic areas, or in patients with relevant history. Successful treatment can be achieved by medical therapy alone, if the patient shows improvement clinically and sonographically--avoiding drainage and orchiectomy.

http://dx.doi.org/10.5489/cuaj.2669

Published online September 9, 2015.

Competing interests: The authors all declare no competing financial or personal interests.

This paper has been peer-reviewed.

References

(1.) Kaya F, Kocygit A, Kaya C, et al. Brucella testicular abscess case presenting as a testicular mass: Can color Doppler sonography be useful in differentiation? Turk J Emerg Med 2014. http://dx.doi.org/10.5505/1304.7361.2014.82698. http://dx.doi.org/10.5505/1304.7361.2014.82698

(2.) Al-Tawfiq J. Brucellaepididymo-orchitis: A consideration in endemic area. Int Braz J Urol 2006;32:313-5. http://dx.doi.org/10.1590/S1677-5538200600030001 1

(3.) Kocak I, Dundar M, Culhaci N, et al. Relapse of brucellosis simulating testis tumor. Int J Urol 2004;11:6835. http://dx.doi.org/10.1111/j.1442-2042.2004.00862.x

(4.) Akinci E, Bodur H, Cevik MA, et al. A complication of brucellosis: Epididymoorchitis. Int J Infect Dis 2006;10:171-7. http://dx.doi.org/10.1016/jdjid.2005.02.006

(5.) Koc Z, Turunc T, Boga C. Gonadal brucellar abscess: Imaging and clinical findings in 3 cases and review of the literature. J Clin Ultrasound 2007;35:395-400. http://dx.doi.org/10.1002/jcu.20330

(6.) Yemisen M, Karakas E, Ozdemir I, et al. Brucellar testicular abscess: A rare cause of testicular mass. J Infect Chemother 2012;18:760-3. http://dx.doi.org/10.1007/s10156-01 1-0354-7

(7.) Gonzalez Sanchez FJ, Encinas Gaspar MB, Napal Lecumberri S, et al. Brucellar orchiepididymidestis with abscess. Arch Esp Urol 1997;50:289-92.

(8.) Castillo Soria JL, Bravo de Rueda Accinelli C. Genital brucellosis. A rare cause of testicular abscess. Arch Esp Urol 1994;47:533-6.

(9.) Fernandez Fernandez A, Jimenez Cidre M, Cruces F, et al. Brucellarorchitis with abscess. Actas Urol Esp 1990; 14:387-9.

(10.) Bayram MM, Kervancioglu R. Scrotal gray-scale and color Doppler sonographic findings in genitourinary brucellosis. J Clin Ultrasound 1 997;25:443-7. http://dx.doi.org/10.1002/(SICI)10970096(199710)25:8<443::AID-JCU6>3.0.C0;2-J

Correspondence: Dr. Sakher Tahaineh, Security Forces Hospital, PO Box. 1 4799, Makkah 21 955, Saudi Arabia; tahineh@yahoo.com

Sakher Tahaineh, MD; * Rawan Abu Mughli, MD; ([yen]) Hanan I Hakami, MD; ([+ or -]) Mohamad I Al-Faham, MD ([yen])

* Department of Urology, Security Forces Hospital, Makkah, Saudi Arabia; ([yen]) Department of Radiology, Security Forces Hospital, Makkah, Saudi Arabia; ([+ or -]) Section of Infectious Diseases, Department of Medicine, Security Forces Hospital, Makkah, Saudi Arabia

Caption: Fig. 1. An image showing the increase in the overall vascularity of the left testis.

Caption: Fig. 2. A repeat ultrasound showing a marked reduction in the size of the abscesses.
Table 1. Characteristics of the patients with Brucella testicular
abscesses

Reference     Age    Duration      Clinical          Relevant
              (yr)      of         features          history
                     symptoms

Kaya           23    2 months        Right            Recent
et al. (1)                        testicular       ingestion of
                                   swelling       unpasteurized
                                                      cheese

Kocak          32    2 months    Left painless      History of
et al. (3)                        testicular         systemic
                                     mass         brucellos-is 3
                                                  years earlier

Akinci         ND       ND            ND                ND
et al. (4)

Koc            42    6 weeks         Right         Ingestion of
et al. (5)                      testicular pain   unpasteurized
                                 and swelling         cheese
                                with fever and
                                 night sweats

Yemisen        42    2 weeks         Right          Works as a
et al. (6)                      testicular pain     teacher in
                                 and swelling     small Turkish
                                  with fever         village

Gonzalez       ND       ND      Left testicular     History of
Sanchez                            pain and          systemic
et al. (7)                         swelling       Brucellosis 4
                                                  months earlier

Castillo       ND       ND            ND                ND
Soria et
al. (8)

Fernandez      ND       ND      Testicular pain     Coexisting
Fernandez                        and swelling        systemic
et al. (9)                                         Brucellosis

Bayram         ND       ND            ND                ND
et al. (10)

Our case       36    6 weeks    Left testicular     History of
                                     pain            systemic
                                                  Brucellosis 3
                                                  months earlier

Reference      Brucella       Blood       Ultrasound findings
              agglutinin     culture
                titer

Kaya           Positive     Negative     Thick-walled abscess
et al. (1)                                measured 31 x 41 x
                                          74 mm replacing the
                                             entire testis

Kocak          positive     Not done          Hypoechoic
et al. (3)                                   heterogeneous
                                         intratesticular mass
                                          measured 63 x 42 x
                                                 38 mm

Akinci         positive        ND         Testicular abscess
et al. (4)

Koc                        Positive B.   Thick walled abscess
et al. (5)     Positive    melitens-is    measured 55 x 50 x
                                                 40 mm

Yemisen        Positive     negative       Hypoechoic cystic
et al. (6)                                lesion measured 20
                                                x 15 mm

Gonzalez       positive        ND         Diffuse enlargement
Sanchez                                   of the left testis
et al. (7)                                with several small
                                               abscesses

Castillo          ND           ND            Large abscess
Soria et                                   causing complete
al. (8)                                  destruction of testis

Fernandez         ND           ND              Increased
Fernandez                                testicular size with
et al. (9)                                  intratesticular
                                                abscess

Bayram         positive    Positive B.     Focal hypoechoic
et al. (10)                melitensis    lesion, mean size 23
                              from                mm
                            specimen
                             culture

Our case       Positive     Negative       Multiple anechoic
              at repeat                    cystic areas with
              dilution of                 internal septation
              1:320 titer

Reference           Treatment

Kaya           D and S for 7 days;
et al. (1)       abscess size did
                not change; it was
               drained, followed by
               D and R for 6 weeks

Kocak              Orchiectomy
et al. (3)        as tumour was
                suspected, then C
                and D for 6 weeks

Akinci           Orchiectomy and
et al. (4)    antibiotic therapy for
                    6-8 weeks

Koc              Abscess drained
et al. (5)     then treated with D
                and R for 4 months

Yemisen        D and R for 6 weeks
et al. (6)

Gonzalez         Antibiotics, but
Sanchez          orchiectomy was
et al. (7)       done due to poor
               response to therapy

Castillo       Double drug therapy,
Soria et         but orchiectomy
al. (8)          was done due to
               complete destruction
                  of the testis

Fernandez        Antibiotics, nut
Fernandez      orciectomy was done
et al. (9)      due to progressive
                enlargement of the
                     abscess

Bayram             Orchiectomy
et al. (10)       as tumour was
                suspected, then D
               and R for 6-8 weeks

Our case         D, C, and B for
                     3 months

D: doxycycline; S: streptomycin; R: rifampicin; C: ciprofloxacin;
B: bactrim; ND: not determined.
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Article Details
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Title Annotation:CASE REPORT
Author:Tahaineh, Sakher; Mughli, Rawan Abu; Hakami, Hanan I.; Faham, Mohamad I. Al-
Publication:Canadian Urological Association Journal (CUAJ)
Article Type:Case study
Geographic Code:7SAUD
Date:Sep 1, 2015
Words:1945
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