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 ~  Abstract
 ~  Materials and Me...
 ~  Case Reports
 ~  Discussion
 ~  Acknowledgement
 ~  References

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CASE REPORT
Year : 2001  |  Volume : 19  |  Issue : 4  |  Page : 208-211
 

Brucellar epididymoorchitis - Report of five cases


Department of Microbiology, BLDEA's Shri BM Patil Medical College, Bijapur - 586 103, Karnataka, India

Correspondence Address:
Department of Microbiology, BLDEA's Shri BM Patil Medical College, Bijapur - 586 103, Karnataka, India

 ~ Abstract 

We report here 5 bacteriologically proven cases of Brucellar epididymoorchitis. Four cases presented with unilateral epididymoorchitis and with bilateral presentation in one case. Blood culture grew Brucella melitensis in all 5 cases. B.melitensis was isolated in testicular aspirate of 4 patients. Brucella agglutinins were demonstrated in testicular aspirate of 4 patients and semen of 2 patients. To our knowledge this is the first report of bacteriologically proven cases of brucellar epididymoorchitis in the world literature.

How to cite this article:
Mantur B G, Mulimani M S, Mangalagi S S, Patil A V. Brucellar epididymoorchitis - Report of five cases. Indian J Med Microbiol 2001;19:208-11


How to cite this URL:
Mantur B G, Mulimani M S, Mangalagi S S, Patil A V. Brucellar epididymoorchitis - Report of five cases. Indian J Med Microbiol [serial online] 2001 [cited 2020 Oct 27];19:208-11. Available from: https://www.ijmm.org/text.asp?2001/19/4/208/8192


 Brucellosis More Details - a zoonotic infection is transmitted from animals to humans by direct contact with an infected animal as in case of shepherds, farm workers and meatpacking employees either through respiratory tract, abraded skin surfaces or conjunctiva and by indirect method by ingestion of infected milk or milk products. The signs and symptoms associated with  Brucellosis More Details are protean in nature, no constellation of clinical findings can be considered characteristic[1] and hence laboratory help is essential in the diagnosis.A definitive diagnosis of  Brucellosis More Details is made by recovering the organisms from blood,fluid or tissue specimens.[2] The complications which may develop during the acute or chronic stages affect bones and joints, cardiovascular system, central nervous system, genitourinary tract and reticuloendothelial system.[3] Complication of  Brucellosis More Details involving the genital tract is very rare.[4],[5] The genitourinary complications of  Brucellosis More Details though reported to be rare in literature,have isolated reports on  Brucella More Detailsr epididymoorchitis by Christie[6] (2-14 %), Khan et al[7] 14 cases and Spink[8] 5 cases. The diagnosis of epididymoorchitis in these studies has been done only on blood specimen where culture identification and or antibodies have been demonstrated. The present study has demonstrated in addition to blood culture and  Brucella More Details serology, isolation of  Brucella More Details organisms and or antibodies from the testicular fluid and or semen.

 ~ Materials and Methods Top

 Brucella More Details antibody demonstration
The serum samples of all 5 cases were subjected for slide agglutination test using B.abortus coloured antigen and standard tube agglutination test using B.abortus plain antigen. The antigens for both the tests were obtained from Indian Veterinary Research Institute, Izatnagar and procedures followed were as per the manufacturer's instructions.
Clear aspirate obtained from the testis of 4 cases was used instead of serum in the above two tests using the same procedure.
To 1 mL of semen obtained from 2 cases, one drop of 1% solution of sodium azide was added and left for 30 minutes. The sample was centrifuged at 1000 rpm for 10 minutes. The supernatant fluid was used instead of serum in the above mentioned tests.[9]
 Brucella More Details culture
The blood specimens obtained from 5 cases were inoculated onto two Castaneda's biphasic media (5 ml in each) consisting of trypticase soy agar and broth .The media were incubated at 37oC with and without CO2 for 1 month. The isolates were identified and biotyped with the help of Gram staining, Kinyon's staining, urease test, H2S production (4 days), dye sensitivity to basic fuchsin (1:50,000 and 1:100,000) and thionin (1:25,000, 1:50,000 and 1:100,000). The agglutination tests were performed on colonies as per the standard procedures[10] using B.abortus and B.melitensis monospecific antisera obtained from Murex Biotech ltd, Dartford, England. The isolates were confirmed at Indian Veterinary Research Institute, Izatnagar.
The  Brucella More Details culture was performed on testicular aspirate obtained from 4 cases using 0.5 mL in each biphasic medium and procedure used was as for the blood culture mentioned above.
Widal test for enteric fever was performed using stained  Salmonella More Details febrile antigens obtained from Span diagnostics Ltd., India and procedure employed was as per the manufacterer's instructions.
Blood was inoculated into bile broth for  Salmonella More Details group of organisms using the standard procedures.[11]
Testicular aspirate without decontamination and semen after decontamination were inoculated onto Lowenstein Jensen's media, incubated under aerobic condition at 37oC for 8 weeks for the isolation of mycobacteria.
A 1oopful of the testicular aspirate and liquefied semen specimens were inoculated onto chocolate agar media, incubated at 350C with 5-10% CO2 for 48 hours for the isolation of Gonococci. In case of semen specimens, Thayer Martin medium was also inoculated.

 ~ Case Reports Top

Subject 1
A 30 year old veterinary inspector was admitted to a hospital in Bijapur on June 12, 1995 with fever, low backache for 1 month and swelling in the right testicle for 1 week. His pulse was 86/min, and temperature 39oC and his liver was enlarged by 2 cm. He had swollen right testis and was found enlarged about twice the normal size. The right testis was tender on palpation. The skin over the swelling was red with local rise of temperature. Haemoglobin was 12.5 gm/dL, Leucocyte count 11.2 x 109/L. Peripheral blood smear was negative for malarial parasites. Widal test and blood culture for  Salmonella More Details were negative.  Brucella More Details serology showed 1280 I.U. agglutinins by standard tube agglutination and semen demonstrated 320 I.U. agglutinins. Blood collected in Castaneda's medium grew B.melitensis biotype 1.
Subject 2
A patient aged 50 years, moderately built and nourished was admitted to a hospital in Bijapur on 24-04-1997. He complained of fever, more in the night with sweats, pain and swelling in the right testicle.Fever was for the past 3 months and of intermittent type. On physical examination the patient was found febrile with body temperature of 39oC. Mild splenomegaly was found. The case was referred to the surgeon for his opinion. Local examination revealed right sided thickened, tender epididymis, right sided tender testicular swelling. The skin over the swelling was red and local rise of temperature was found. A provisional diagnosis of epididymoorchitis was made. Blood routine investigations such as haemoglobin, total leucocyte count, differential leucocyte count, ESR were within normal limits. Peripheral blood smear was negative for malarial parasites. Urine routine investigations for albumin, sugar and microscopy revealed no abnormality. Widal test was negative. Chest X-ray was normal. Blood specimen demonstrated  Brucella More Details agglutinins of 320 I.U. and grew B.melitensis biotype 3. The semen and testicular aspirate showed  Brucella More Details agglutinins to a dilution of 80 I.U. Testicular aspirate grew B.melitensis biotype 3. Semen, testicular aspirate did not grow other bacteria. The diagnosis of  Brucella More Detailsr epididymo-orchitis was made.
Subject 3
A 25 year old farmer was seen on August 12, 1998 with a 2 month history of fever, headache, knee joint pain and swelling of right testis. Physical examination showed fever (400C), enlarged spleen measuring in size of 4 cm below the costal margin and enlarged liver to a size of 2.8 cm below the costal margin and right sided tender testicular swelling. Blood specimen showed mild leucocytosis, negative for malarial parasites. Widal test was negative for enteric fever. Serum  Brucella More Details antibodies were positive to a dilution of 320 I.U. and testicular aspirate demonstrated  Brucella More Details agglutinins to a dilution of 80 I.U. Blood specimen and testicular aspirate showed the growth of B.melitensis biotype 1. Blood and testicular aspirate cultures were negative for other bacteria.
Subject 4
A 20 year old man presented with fever, generalised bodyache, knee joint pain, low backache and right sided testicular swelling to B.L.D.E.A'S Shri. B.M. Patil Medical College hospital, Bijapur on 26 August, 1999. He had fever and generalised bodyache since 1 year. He noticed testicular swelling one month prior to the admission. In serum,  Brucella More Details agglutinins were positive to a titre of 640 I.U.  Brucella More Details agglutinins were found positive in the testicular fluid (160 I.U.). B.melitensis biotype 1 was isolated from the blood as well as testicular fluid. A diagnosis of  Brucella More Detailsr epididymoorchitis was made.
Subject 5
The patient was a 35 year old and presented on october 24, 1999 with fever, knee joint pain, lowbackache, generalised body ache and pain and swelling of testicles. Fever, knee joint pain, low backache, generalised body ache were for the past 2 years,where as pain and swelling of testicles for the past 3 months. Fever was intermittent type, not associated with sweats. Physical findings included fever (400C), tender, swollen testicles, skin over the swollen testicles was red and shiny. Palpation of swollen testicles demonstrated local rise of temperature. No abnormality on abdominal clinical examination was seen. Serum  Brucella More Details antibodies were positive to a dilution of 320 I.U. and 80 I.U. agglutinins were demonstrated in the testicular fluid. Blood specimen and testicular fluid grew B.melitensis biotype 1.
The above cases were put on standard regimen consisting of tetracycline orally 2g/day in 4 divided doses for 6-8 weeks together with streptomycin 1g daily intramuscularly for first 2-4 weeks depending on resolution of signs and symptoms. Subjects 1, 2 and 5 showed an improvement and 3 and 4 did not come back for follow up.

 ~ Discussion Top

 Brucellosis More Details is widespread throughout the world, having been eradicated in only a few areas. The disease remains hyperendemic in Kuwait, Saudi Arabia, Iraq, Iran, Algeria, Tunisia, Morocco, Malta, Egypt, India.[12] The commonest complications are thrombophlebitis, spondylitis and arthritis especially of the hip, knee and shoulder, but any system can be involved. Complications of the genitourinary tract are rare.[4],[5] Acute orchitis or epididymoorchitis with signs of systemic infection do occur.[5]  Brucellosis More Details of the genitourinary tract has been reviewed by Forbes and his associates.[13] Orchitis and especially epididymoorchitis are occasional complications of  Brucellosis More Details.[14],[15] In the University of Minnesota series there were five patients who presented with the signs and symptoms of orchitis or epididymoorchitis or whose previous clinical course had included these complications leading to an incidence of 2%.[8] Romero et al[16] have reported only one case of  Brucella More Detailsr epididymitis in a total of 150 cases orchiepididymitis studied in 7 years. Estimation of the incidence of the epididymoorchitis in  Brucellosis More Details has ranged from 2-14 %.[6] This infection as a cause of epididymoorchitis being less likely to be overlooked in regions where it is known to be enzootic. Over a period of 12 years from 1988-2000, of the 459 patients with  Brucellosis More Details reported, only 5 cases (1.08%) comprised of the  Brucella More Detailsr epididymoorchitis in the present series. In men, unilateral epididymoorchitis is the usual manifestation[8] which is our experience also. In 4 out of 5 cases in the present series had unilateral involvement while in one both testicles were involved; bilateral involvement is also reported in the literature.[8],[17] In a series of 14 cases of  Brucella More Detailsr epididymoorchitis reported by Khan et al[7] 5cases by Spink,[8] 2-14 % by Christie,[6] 14 cases by Yurdakul T et al18 diagnosis was based on  Brucella More Details serology and blood culture. In contrast we are reporting 5 cases of epididymoorchitis where in the diagnosis of  Brucella More Detailsr epididymoorchitis was established not only by blood culture and or serology but also by demonstrating the organisms and or antibodies in the testicular aspirate in 4 cases and patient's semen (antibodies) in 2 cases. The prognosis is good and with treatment most patients recover without sequelae.[19] All the 3 cases reported for follow up responded well to a combination therapy of tetracycline and streptomycin.

 ~ Acknowledgement Top

Authors gratefully acknowledge Dr. V.K. Yadava, Dr. V.N. Bachhil, Head, Division of Veterinary public health IVRI, Iztnagar and Dr.D.K. Singh, Scientist,  Brucellosis More Details Laboratory, IVRI, Izatnagar for confirming the isolates. 

 ~ References Top

1.Mandell GL, Douglas RG, Bennett JE. Principles and practice of infectious diseases 3rded In: Brucella species. Mikolich DJ, Boyce JM Eds, 1990:1735-1742.  Back to cited text no. 1    
2.Young EJ. Serologic diagnosis of human brucellosis. Analysis of 214 cases by agglutination tests and review of the literature, Rev infect Dis 1991;13:359-372.  Back to cited text no. 2    
3.Dalrymple - Champneys W. Brucella infection and undulant fever in man, Oxford University press, London, 1960.  Back to cited text no. 3    
4.Mandell GL, Bennett JE, Dolin R. Principles and practice of infectious diseases, 4th ed vol 2 In: Brucella species. Young EJ Ed, 1995: 2053-2060.  Back to cited text no. 4    
5.Armstrong D, Cohen J. Infectious diseases 1st Ed, vol 2, In: Brucellosis Black FT,Ed, 1999; 6: 34:15-34:16.  Back to cited text no. 5    
6.Christie AB. Infectious diseases. Epidemiology and clinical practice, London, Churchill Livingstone, 1980.  Back to cited text no. 6    
7.Khan MS, Humayoon MS, A 1 Manee MS. Epididy moorchitis and brucellosis, Br J Urol 1989; 63:87-89.  Back to cited text no. 7    
8.Spink WW. The nature of brucellosis, Minneapolis, University of Minnesota press, 1956.  Back to cited text no. 8    
9.Brinley Morgan WJ, Mackinnon DJ, Gill KPW, Gower SGM, Norris PIW. Brucellosis Diagnosis standard laboratory techniques. 2nd Ed, 1978:1-52.  Back to cited text no. 9    
10.Alton GG, Jones LM, Pietz DE. Laboratory techniques in brucellosis, 2nd Ed 1975; 1- 163.  Back to cited text no. 10    
11.Sonnenwirth AC. Collection and culture of specimen and guide for bacterial identification In: Gradwohl's Clinical Laboratory Methods and Diagnosis (1980) Vol 2, 8th edn. Sonnenwirth AC, Jarett Leds.CV Mosby company. StLouis Missouri USA. 1560-1570.  Back to cited text no. 11    
12.Hall WH. Modern chemotherapy for brucellosis in humans, Rev.infect Dis, Vol 12, No.6, November-December, 1990: 1060 -1099.  Back to cited text no. 12    
13.Forbes KA, Lowry EC, Gibson TE, Soanes WA. Brucellosis of the genitourinary tract- review of the literature and report of case in a child, Urol Surv 1954; 4:391-412.   Back to cited text no. 13    
14.Diaz Castro H. Brucellosis genital en el hombre, Arch, urug. demed, cir,y especialid 1946;29:61 and 148.  Back to cited text no. 14    
15.Issac AG. Orchitis and epididymitis due to undulant fever, J urol 1938; 40:201.  Back to cited text no. 15    
16.Romero PP, Navarro IV, Amati CM, Villanueva GR. Brucellar orchiepididymitis in acute brucellosis, Actas urol Esp 1995; 19(4): 330-2.  Back to cited text no. 16    
17.Afsar H, Baydur I, Sirmatel F. Epididymoorchitis due to brucellosis, Br J Urol 1993; 72(1): 104-5.  Back to cited text no. 17    
18.Yurdakul T, Sert U, Acar A, Karalezli G, Akcetin Z. Epididymo orchitis as a complication of brucellosis, Urol Int 1995; 55(3):141-2.  Back to cited text no. 18    
19.Gorbach SL, Barlett LG, Blacklow NR. Infectious diseases 2nd edition In: Brucella Gotozzo E, Carrillo L.Eds. 1998;1839-1845.  Back to cited text no. 19    
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