An 18-year-old male complained of right lumbago and pain in both knees, since one and a half months before admission. The pain was resolved several days after consumption of nonsteroidal anti-inflammatory drugs (NSAIDS), while no antibiotic was taken; after that, the subject had no symptom for almost one month. He consulted the infectious clinic while complaining of fever and severe pain and swelling in left testis over the last four days. He had a history of unpasteurized ice cream consumption, but no history of urinary tract infection, sexual contact, genitalia trauma, surgery or urinary catheterization and had completed his vaccination series. He did not have dysuria, frequency, cloudy urine, urethral discharge, or blood in the semen. After the examination, the cardiovascular and respiratory systems and abdomen were found normal. There was no swelling in parotid glands and inguinal adenopathy. The scrotal skin was erythematous, warm and was freely moving on testis. Left testis was enlarged, hard, and tender. Rectal exam was normal. He was admitted to the hospital for the treatment of epididymo-orchitis and also ruling out the brucellosis. Empirical antibiotic therapy was instituted; initially he received IV fluoroquinolone. To provide symptomatic relief, analgesics, scrotal elevation and ice pack were advised. After a few days, there was no clinical response, therefore meropenem was added to ciprofloxacin. After almost one week of antibiotic therapy, the sign and symptoms of testis and scrotum infection just slightly changed. In addition, the musculoskeletal pain relapsed, thus empirical therapy with doxycycline and rifampin was started and a few days later, the signs and symptoms significantly decreased.
2.1. Paraclinical Results
WBC: 11700 per µL (Neut: 78%), Hb: 13.4 g/dL, plt: 184000 per µL, CRP: 96, ESR: 23, BUN: 38 mg/dL, Cr: 1 mg/dL, VDRL: negative, αfp: 1.7 (< 5.8) ng/mL, BHCG: < 1 (up to 2.6) mIU/mL, LDH: 223 (250-500) IU/L, Wright: 1/40, Combs-Wright: 1/80, 2ME: 1/40, anti-
Brucella ELISA: positive; PPD: negative; U/A: normal; culture of urine, blood and needle scrotal drainage were negative; chest X-ray, abdominal and pelvic sonography, and also sacroiliac CT-scan were normal.
Ultrasonography of urinary system: kidneys, bladder, ureters, urethra and right testis were normal. Left testis was 61 × 26 mm which was bigger than normal size. Echogenicity of left testis was heterogeneous. In addition, one hypoechoic mass (8.5 × 4.5 × 9.5 mm) with ill-defined border was observed which probably recommended early stage of abscess formation. Other findings were also reported including slight thickness in left scrotum, the large size of the left epididymis containing one ill-defined hypoechoic area, and mild hydrocele with septation around the left testis.
Scrotal scan: after IV injection of Tc99m-pertechnetate, scanning was performed in the anterior projection, the scan revealed no significant abnormal radiotracer activity in both sides; no clear evidence of pathology of scrotum was detected.
Based on these findings and the clinical response to anti-brucellosis treatment, the patient was discharged with doxycycline and rifampin. During the follow-up, after almost one month, the pain and swelling of the left testis completely disappeared, but in its examination, a small nodule was detected.
The second ultrasonographic findings revealed: right testis measured 42 × 19 mm with normal echo pattern, the left side one, measured 46 × 25 mm and heterogeneous hypoechoic and hypervascular mass like lesion was observed at its upper pole about 18 × 15 mm, suggestive of neoplastic pathology. In addition, the left side epididymal structures were engorged and thickened. No hydrocele was detected and also grade I varicocele was observed at left side. No obvious para-aortic adenopathy was defined. Arterial flow pattern at both testes as well as other parts were normal.
The patient was referred to an urologist and underwent a surgery. In operation room, based on frozen section technique, highly suggestive of malignant lesion was reported. Therefore left sided radical orchiectomy was immediately performed. The diagnosis was made after orchiectomy.
On gross examination of the pathology sample, one solid nodular soft gray-tan mass, measuring 3 cm was observed in the central portion of testis. The microscopic examination included the seminiferous tubules and interstitium that were infiltrated by granulomas of non-necrotizing type, rich in plasma cells. The epididym, showed chronic nonspecific inflammation (
Figures 1 and 2).
After surgery he completed the medical therapy for brucellosis, and in the follow up periodic visit during two years, he had no complaints, abnormal physical or paraclinical findings (including WBC, ESR, CRP and ultrasonography).
Figure 1. Granulomatous Orchitis Under 10x Objective
Figure 2. Granulomatous Orchitis Rich in Plasma Cells Under 40x Objective