Subject Areas: Infectious Diseases
Brucellosis is a zoonotic disease frequently seen in many societies and known all over the world with its complications  . It is reported to be seen as hyper endemic especially in the countries around the Mediterranean Sea  .
Although its most common finding is arthralgia, infection can invade all organs and in this way complications can be seen in the invaded organs  . Its clinical course can be seen in three ways. Acute infection period is the profile presenting symptoms in the first two months after infection. Subacute infection is the profile that occurs when symptoms continue between two months and one year, and chronic infection is the profile happening when the symptoms last more than one year  . The most common first period findings are peripheral arthritis and sacroiliitis. Swelling in joints, rash, limited movement and radiological findings direct the diagnosis. In 2% - 20% of brucellosis patients, prostatitis, epididymoorchitis, cystitis, piyelonephritis, interstitial nephritis, exudative glomerulonephritis and renal abscess can be seen  . Epididymoorchitis was defined as swelling and pain in the scrotal dermis, testis and epididymis  . Because these symptoms are non-specific, the infections caused by Brucella spp. of urinary system can be disregarded  . In patients with epididymoorchitis, granulomatous type inflammation can be seen  . Epididymits caused by Brucella spp. can cause severe complications such as necrotizing orchitis, aspermia, and oligospermia if they are not treated.
2. Case Report
A 60 years-old man was admitted to urology clinic because of fever up to 38˚C, dysuria, pollakuria, back and legs pain, weakness. He also reported that he had been swollen and painful testicles for more than 10 days but symptoms were not in regress. In the physical examination, swelling and pain in the scrotal dermis, and testis were palpated. Patient had unilateral epididymoorchitis. Other systemic examinations were normal. During this stage results of laboratory tests had been found as follows; white blood cell count 9100 uL, erythrocyte sedimentation rate 78 mm/h, C reactive protein: 114.6 mg/L, AST: 13 IU/L, ALT:11 IU/L, hepatitis markers were negative, urinalysis was normally. Patient had a history of unpasteurized dairy product ingestion. Rose Bengal agglutination test (Plasmatec) was performed to patients with suspected brucellosis and result was posi- tive. Antibodies titers of brucellosis were reported as 1:640 in serum with Coombs Brucella (Metser LAB, Turkey) test. Therapy with oral doxycycline (100 mg every 12 h) and oral rifampicin (600 mg every 12 h) was administered. After 5 days of treatment patient’s symptoms were dramatically regressed. Three months after, stopping of the therapy, laboratory tests were as fallows; AST: 17 IU/L, ALT: 21 IU/L, urinalysis was normal and Coombs Brucella (Metser LAB, Turkey) titers of brucella antibodies in serum were subsided to 1:160. After maintenance treatment, all symptoms of the patient were regressed.
Brucellosis transmitted from infected animals to humans, widespread all over the world as zoonosis, is transmitted through consumption of contaminated food, direct inoculation, contact with infected animals, or inhalation of infectious particles  . Pasteurization of milk and milk products and procedure of boiling kills Brucella spp. bacilli. The cases where there are transmissions through the breast milk of infected mother and human semen have been reported  -  .
In the areas where it is endemic, the bacteria have been shown to be alive up to eight weeks especially in unpasteurizied white soft cheese  . Several serological tests (Rose Bengal, 2-Mercaptoethanol, Wright, Coombs Brucella, Complement fixation and ELISA test) are used for diagnosis of brucellosis  . Serological tests are important for both diagnosis and follow-up treatment.Rose Bengal test is traditionally used for rapid screening in many country. In endemic areas, serologic testing is considered to be diagnostic when titers of 1/320 to 1/640 are present, while titers of 1/160 are considered suspicious. The sensitivity and specificity of serologic tests are generally very high for Brucella spp.  . Brucella Coombs test titres are a good marker of infection activity independent of disease stage  .
Kurtaran et al. found epididymoorchitis rate to be 10/136 (7%) in male group of 136 and average age to be 41 ± 14.7  . Güneş et al., after having probed 15 epididymoorchitis cases between 15 - 51 years of age, reported that the symptom which was the most frequently seen in fifteen cases was testicular pain, the most frequently established finding was scrotal swelling and the most frequently seen laboratory finding was the elevation of the C reactive protein (CRP)  . Erdem et al. examined a total of 390 (352 male, 90.2%) genitourinary brucellosis cases in the multicentric study in which 34 centers were involved  . It was reported that in male patients, the most frequent involved site was the scrotal area (n = 327, 83.8%) as epididymo-orchitis (n = 204, 58%), orchitis (n = 112, 31.8%) and epididymitis (n = 11, 3.1%). Additionally, in female patients, pyelonephritis (n = 33/38), 86.8%) was significantly higher than that in male patients (n = 11/352, 3.1%) in this study  . Erythrocyte sedimentation rate (ESR) and CRP showed moderate increases. Orchiectomy and abscess drainage had been performed in nine (2.3%) patients. Erdem et al. detected that therapeutic failure was in 6 (1.5%), relapse occurred in 4 (1%), and persistent infertility related to brucellosis occurred in one patient  . Gür et al. detected epididymoorchitis in 14 of 145 male patients  . 10/14 (71%) of these cases are between 15 - 45 years of age. Demiroğlu et al. detected that genitourinary involvement was 5.3% in 151 brucellosis cases (age range 15 - 79 years; 89 female)  . In this study, doxycycline + rifampicin combination during six weeks was the most preferred one among seven different therapy protocols. A total of 1028 brucellosis cases were evaluated with retrospective analysis over a 10-year period  . Buzgan et al. found that acute cases were seen intensively in spring (30.6%), subacute cases were mainly seen in the autumn (33.8%). May and September were the peak months of acute cases. Twelve cases (1.2%) were found to be seronegative  . Genitourinary system involvement was found in 38 (3.7%) patients. Brucella spp. was isolated from semen in a patient who has prostatitis  . Epididymoorchitis was observed in 35 cases (3.4%), being bilateral in three cases. Orchiectomy was performed to three cases because of testicular abscess formation  .
We emphasize that the training of society on brucellosis and its complications and the care in medical approach should be increased especially in geographic areas where the disease is endemic. The physicians should follow radiological imaging results and laboratory results about severe complications. Accurate diagnosis rate will increase when serological results positive in low titer and uncommon clinical presentation are closely followed. Additionally, control and eradication of brucellosis depends on the education of farmers, veterinarians and the general public.
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