SHORT REPORTOpen Access
An unusual complication of a common endemic
disease: clinical and laboratory aspects of patients
with brucella epididymoorchitis in the north of
Narges Najafi, Roya Ghassemian, Ali R Davoody*and Atefe Tayebi
Background: Brucella epididymoorchitis(BEO) is a focal complication of human brucellosis and has been reported
in 2-20% of patients with brucellosis. Brucellosis is an endemic disease in Iran. The incidence of the disease in this
country is 34 per 100 000 per year.
Methods: In a retrospective study, we identified 30 cases of Brucella epididymoorchitis in two teaching hospitals in
the north of Iran during 1997-2009.
Findings: Epididymoorchitis occurred in 11.1% of male patients with brucellosis. The average age was 25.5 ± 12.43
years. Pain and scrotal swelling (100%) and fever (96.7%) were the most common symptoms. Different treatment
regimens were administered including doxycycline plus rifampin (60%), doxycycline plus rifampin plus
aminoglycoside for the first two weeks (36.6%) and doxycycline plus cotrimoxazole(3.4%). Ten percent of the
patients did not respond to antibiotic therapy and required surgical drainage or orchiectomy.
Conclusions: In brucellosis endemic areas, clinicians who encounter patients with epididymoorchitis should
consider the likelihood of brucellosis. A careful history and physical examination and an immediate laboratory
evaluation help to make a correct diagnosis. Generally, classical therapy of brucellosis is adequate for the treatment
Keywords: Brucellosis, Epididymoorchitis, Testicular abscess
Brucellosis is an endemic zoonotic disease that can
involve many organs and tissues. The incidence of bru-
cellosis in developed countries is low, but it occurs spor-
adically in occupationally exposed groups, including
farmers, veterinarians, and laboratory and slaughter-
house workers [1,2]. Brucellosis is an endemic disease in
Iran. The incidence of the disease in this country is 34
per 100 000 per year . Brucella epididymoorchitis
(BEO) is a focal complication of human brucellosis and
has been reported in 2-20% of patients with brucellosis
[4-6]. Brucella species were first described as a cause of
granulomatous orchitis in humans by hardy in 1928 .
Since then, many authors have reported sporadic cases
of Brucella orchitis worldwide [5-15]. BEO can cause
serious complications such as necrotizing orchitis, and
therefore it must be considered in the differential diag-
nosis of acute epididymoorchitis in endemic areas
[4,8-10]. However, genitourinary complications of bru-
cellosis have been documented only rarely in the medi-
cal literature [5,8,9]. BEO is relatively uncommon in
developed countries because brucellosis has been eradi-
cated generally in animals. Nevertheless, cases have been
reported in patients from other countries where the dis-
ease is endemic, or in people who have traveled to these
areas and have consumed unpasteurized dairy products
[2,5-7]. In the present study, we describe the clinical
characteristics, treatment, and final outcome of 30
patients with Brucella epididymoorchitis who were
* Correspondence: email@example.com
Department of infectious disease, North Iranian tropical and infectious
disease research center, Mazandran university of medical sciences, Iran
Najafi et al. BMC Research Notes 2011, 4:286
© 2011 Davoody et al; licensee BioMed Central Ltd. This is an open access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.
hospitalized in two teaching hospitals of Mazandaran
University of Medical Science (Razi hospital and Imam
Khomeini hospital) during 1997-2009.
Among 447 patients confirmed to have brucellosis who
were admitted to Razi and Imam Khomeini hospitals in
the north of Iran during 1997-2009, thirty patients met
the criteria of this study. The diagnosis of brucellosis
was made by the isolation of Brucella species from
blood culture or by using a standard tube agglutination
test, with a titer of ≥ 1:160, the Rose Bengal test (posi-
tive flocculation reaction), the Coombs test, with a titer
of ≥ 1:160, and the 2ME test, with a titer of ≥ 1:80 for
antibodies to Brucella according to standard methods
. The results were considered in combination with
compatible clinical findings (e.g. orchitis and fever,
sweating, arthralgia, hepatomegaly, splenomegaly, and
other signs of focal disease). The diagnosis of epididy-
moorchitis was based on the presence of clinical symp-
toms of orchitis such as scrotal pain and swelling.
Ultrasonography and other diagnostic imaging studies
were performed as appropriate for the symptoms of the
patients. The patients were assessed initially, on days 14
and 45, and at the end of therapy. Histological finding
were described for one patient who required orchiect-
omy. For each patient a questionnaire was used to
abtain information on demographics, clinical findings,
laboratory results, treatment, and outcome and the data
were analyzed using SPSS descriptive statistical tests.
A total of 447 cases of brucellosis were diagnosed of
which 268 were in males. BEO was diagnosed in 30 of
the male patients, hence an incidence of 11.11% in
males and 6.70% in all patients with brucellosis was cal-
culated. The mean age of the patients with BEO was 25
± 12.4 (range, 14-61) years. Sixteen patients (53.3%)
were living in rural areas. The most common seasons of
occurrence of the illness were spring and summer (13
cases, 43.3% and 12 cases, 40% respectively). Twenty-
one patients (70%) had a history of consumption of
unpasteurized dairy products, which is the main risk
factor for contracting brucellosis, and nine patients
(30%) had occupational exposure. Twelve patients (40%)
had consumed unpasteurized dairy products as well as
being at occupational exposure. One case presented
with a relapse of brucellosis, but he had neither con-
sumed unpasteurized dairy products nor had any occu-
pational contact. The most common presentation was
scrotal pain and swelling. Scrotal pain and swelling,
fever and sweating were the most common symptoms of
the disease. Lower urinary tract symptoms were found
in 33.3% of the patients (Table 1).
The erythrocyte sedimentation rate (ESR) was mea-
sured in 28 patients. The mean ESR was 36.82 ±
27.92mm/h. The ESR was abnormal in 57% of cases, and
28.55% of patients had ESR > 50mm/h. Anemia (Hb <
14g/dl) was found in 28 patients (93.3%). The platelet
counts were normal in all the patients, but leukocytosis
(WBC > 12000 mm3) was found in 10 cases (33.3%).
The level of hepatic transaminase was normal in 28
patients, although it showed a slight increase in two
patients. Renal function tests were consistently normal.
Urine analysis was also normal in 28 patients (93.3%).
Two patients had hematuria and pyuria (6.7%). The
Rose Bengal test showed a positive flocculation reaction
in all patients. The standard tube agglutination tests and
Coombs tests were positive with a titer ≥ 1:160 (1:160-
1:2560) in all patients. The 2ME test was also positive in
all of the patients (1:80-1:640). Ultrasonography showed
unilateral involvement of the epididymis and testis in 26
patients (86.7%), and bilateral involvement was observed
in 4 cases (13.3%). Eighteen patients (60%) had orchitis
without any change in the epididymis. A testicular
abscess was noted in five patients (15%). The mean time
that elapsed between admission and initial therapy was
1-7 days (mean: 2.43 ± 1.57 days). All patients received
different regimens of orally administered antibiotics, as
follows: doxycycline and rifampin in 18 cases (60%),
doxycycline and rifampin along with parenteral amino-
glycoside for the initial two weeks in 11 cases(36.6%),
doxycycline and trimetoprime-sulfamethoxazole in one
patients. The average duration of antimicrobial therapy
was 45-60 days. Ninty percent of the patients were trea-
ted successfully with antimicrobial therapy and experi-
enced rapid regression of symptoms, including
defeverscence and diminished scrotal swelling. In this
series of patients with BEO, there were no clinically
Table 1 Specific signs and symptoms in 30 patients with
Scrotal pain and swelling30100
Fever (temp ≥ 38°c)2996.7
Anorexia 25 83.3
Urinary frequency6 20
Weight loss4 13.3
Lumbosacral pain4 13.3
Najafi et al. BMC Research Notes 2011, 4:286
Page 2 of 4
significant differences observed among the different
treatment groups. Three patients (10%) failed to respond
to medical therapy. Ultrasonography showed a testicular
abscess in all three cases, and the three patients under-
went surgery. Of these, two patients responded to drai-
nage of the abscess and the other required orchiectomy.
The average duration of hospitalization was 7.8 ± 4.5
(range: 3-21) days.
Infections caused by organisms of the genus Brucella
can produce orchitis in susceptible mammals, including
humans . Brucellosis is a relatively common cause of
BEO in some geographic areas, including Iran, where
Brucella melitensis is endemic. Only a few case series
from Iran that discuss Brucella epididymoorchitis have
been published. Rates of epididymoorchitis in cases of
human brucellosis have ranged from 2-20% in various
In the current study, epididymoorchitis occurred in
6.70% of all patients and 11.11% of male patients with
brucellosis in a 13 year period. In a previous study of 96
patients with epididymoorchitis in Imam Khomeini hos-
pital (1995-1996) BEO was found in 14.6% of cases.
Navarro reported BEO in 6% of patients in his study
(1988) in Spain , but in Guindu-Sevillano’s study,
12.8% of cases of epididymoorchitis in Spain were due
to Brucella infection . Memish et al. reported BEO
in 1.6% of their patients with brucellosis . A seven
year study in Turkey (Yurdakal et al.) revealed BEO in
17% of all cases with epididymoorchitis. The rate of
epididymoorchitis in our patients was similar to that
reported from other studies in endemic areas.
The diagnosis of scrotal disease was based on clinical
findings and laboratory data. BEO can be distinguished
from other acute nonspecific types of orchitis by various
clues, including: gradual onset and longer duration,
positive contact history with animals or unpasteurized
dairy products, typical undulant fever, and abnormal
urologic findings. In most of our patients, as in other
studies, fever, scrotal pain and swelling were found, but
signs and symptoms of urinary infection were observed
in 30% of patients.
In a previous study in Sari Imam Khomeini hospital,
signs and symptoms of lower urinary tract infection
were found in 28% of patients . In contrast, signs
of urinary tract infection were observed in 7% of cases
in Spain  and 19.2% in Saudi Arabia [5,6]. Khan et
al,  found lower urinary tract symptoms in 69% of
patients, but the other authors describe a characteris-
tic absence of these symptoms in patients with BEO
[5,6,13]. According to the different reports of the
signs and symptoms of urinary tract infection, we can-
not use this finding as a diagnostic criterion for BEO.
We must consider BEO in every patient with scrotal
swelling and fever, without paying any particular
attention to urinary symptoms. The hematological
findings are usually non specific and cannot help with
the diagnosis of BEO. These disturbances are usually
mild. A low level of hemoglobin may be the result of
prolonged infection and a moderate elevation in ESR
is found in most cases. Most reports describe no
changes in urinary sediment, but in our study we
noticed a change in two patients, who showed hema-
turia and pyuria, similar to some patients in the Span-
ish study . Liver function tests disclosed a mild to
moderate increase in the serum level of hepatic trans-
aminase. These abnormalities in liver function tests
may be caused by granulomatous Brucella hepatitis,
However, when serious liver malfunction is found,
intercurrent disease must always be excluded . In
our series, 16.7% of patients had mild elevation in
liver function tests.
The diagnosis of brucellosis was made by isolation of
Brucella species from blood cultures or epididymal aspi-
rates, or by standard tube agglutination tests, revealing a
titer of antibodies to Brucella antigen of ≥ 1:160, in
addition to compatible clinical findings . Standard
urine culture is inadequate for the diagnosis of genitour-
The presumptive diagnosis of Brucella orchitis can be
made by serological testing [4-6,15]. Positive results
(titers of antibodies to Brucella species of > 1:160 with
the standard tube agglutination test) are common. How-
ever, low titers determined by the standard tube aggluti-
nation test have been reported, and rarely, some
patients with brucellosis have positive blood cultures
but negative serological results .
In our study, all of the patients had standard tube
agglutination titers ≥ 1:160 and those of 2ME > 1:80.
Ultrasonography plays an important role in the diagno-
sis, assessment and management of patients with BEO
. Ultrasonography is more useful in excluding the
possibility of abscess or tumor than in helping to estab-
lish the primary clinical diagnosis . The most notable
ultrasonographic finding was an enlarged and heteroge-
neous epididymis, predominantly the body and tail. Tes-
ticular involvement consisted of a diffusely hypoechoic
testis or focal intratesticular areas. Thickening of the
scrotal wall and tunica albuginea, and moderate hydro-
cele were also noted occasionally [4,16]. Unilateral epidi-
dymoorchitis is the most common genitourinary
complication of brucellosis. Infection limited to the tes-
tis is rare; the epididymis is usually involved in patients
who have acute inflammation [4,5,16]. In the normal
epididymis, very few or no vessels are seen on color
Doppler sonogram, but the size and number of vessels
increase if the epididymis is inflamed. The changes seen
Najafi et al. BMC Research Notes 2011, 4:286
Page 3 of 4
in color Doppler images occur sooner than the changes
evident on a sonogram [4,5,16].
In our series, 86.4% of patients had unilateral testicu-
lar involvement. All of our cases had testicular involve-
ment, and in 40.1% this was accompanied by epididymal
involvement. In the study that was conducted in Spain,
91% of patients had unilateral involvement. Epididymitis
was found in 41.1% of the cases and changes in echotex-
tures of the testis were detected in 82% of sonograms.
The lower number of patients with epididymal involve-
ment reported in our series could be a result of the lack
of use of color Doppler sonograms for diagnosis.
The existence of a hypoechoic lesion in the testis
sonogram is a sign of testicular abscess formation, and
surgery is usually needed in these cases [4,5]. In our
study, abscess formation was observed in five patients
(16.7%), of which two cases responded to medical treat-
ment. Drainage of the abscess was performed for two
cases and orchiectomy in the other.
In a study conducted in Spain, 81% of the patients
underwent surgery . In the other studies reviewed the
need for surgery was lower. The relatively high fre-
quency of surgery in our patients was probably a result
of the fact that the urology center in Imam Komeini
hospital is a referral site. Necrotizing orchitis is a rare
form of Brucella infection, which must be distinguished
from necrotizing involvement arising from other patho-
gens (eg. Mycobacterium tuberculosis, Salmonella spe-
cies) [4,5]. In addition, some acute cases may be
mistaken for urinary tract infections with Gram-negative
pathogens . In brucellosis endemic areas, clinicians
who encounter epididymoorchitis should consider the
likelihood of brucellosis. A careful history, a meticulous
physical examination and a rapid laboratory evaluation
will assist the diagnosis. Clinical and serological data are
sufficient for diagnosis. Conservative management with
a combination of antibiotics is adequate for the manage-
ment of most cases of Brucella epididymoorchitis.
We thank members of staff of the records wards of Ghaemshahr Razi
hospital and Sari Imam Khomeini hospital for their help with the data
All authors are employees of Mazandran University of medical sciences.
Hence all authors receive salaries from the same institution. No other
funding was required for this study. The funders had no role in study
design, data collection and analysis, decision to publish, or preparation of
*Informed written consent was received for the hospital/patient data.
NN participated in the design of the study and was involved in drafting the
manuscript. RG made contributions to the conception and design of the
study and participated in acquisition of data. ARD made contributions to the
acquisition of data performed the statistical analysis and helped to draft the
manuscript. AT made contributions to the acquisition of data, the analysis
and interpretation of the data, and helped to draft the manuscript. All
authors have read and approved the final manuscript.
The authors declare that they have no competing interests.
Received: 8 March 2011 Accepted: 11 August 2011
Published: 11 August 2011
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Cite this article as: Najafi et al.: An unusual complication of a common
endemic disease: clinical and laboratory aspects of patients with
brucella epididymoorchitis in the north of Iran. BMC Research Notes 2011
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